Healthcare » Case Study Library

Revenue Cycle Management
Success Stories

In our healthcare success story library, you will read how providers across the nation have improved financial performance, created better business processes, and enhanced the patient experience through their partnership with Convergent. Let us put our regulatory expertise, consumer-focused patient contact center technology, unique attorney-driven approach, and industry-leading best practices at work for you.

Battle For Authorization

Regulatory knowledge applied to overturn authorization denial

A claim was denied by Blue Cross Blue Shield (BCBS) for no authorization of a follow up test performed three months after an Essure procedure (a form of birth control). The surgeon did not obtain an authorization…
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Denied Healthcare Claim Overturned

Convergent Battles for Appeal on a Denied Healthcare Claim for a Kentucky hospital

This claim was denied because the patient had already proceeded through a long course of fertility services, and that course of treatment had already exhausted the full extent of fertility benefits in…
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Texas Workers’ Compensation Carrier Pays $1.125 Million

Convergent’s regulatory knowledge of Texas Workers’ Compensation pays off for provider

This claim involved the provision of services that ended up exceeding $1.6 million in care, relating to a workers’ compensation case. Upon placement of the case, Convergent immediately initiated direct…
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Assignment of Benefits Not Necessary

Full reimbursement on unusual claim denial

Paramount denied this claim based on a determination that an assignment of benefits was needed from the patient.
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Additional Documentation Sought for Underpaid Claim

Convergent guides hospital through additional documentation review process to receive additional payments from payer.

The hospital admitted a patient for seven inpatient days. The patient had coverage with Medi-Share, a religious non-profit organization that is not an actual insurance company. Upon receipt of the claim,…
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Settlement Agreement Reached on Retracted Payment

Convergent works with patient’s attorney during Worker’s Compensation Claim case

This case involved a patient who was admitted for an 18 day inpatient trauma stay. Horizon Blue Cross issued payment on the claim, but subsequently retracted this payment based on a determination that…
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No Fee Schedule on Arizona Workers’ Compensation Claim

Lack of Fee Schedule Poses No Challenge for Payment Resolution for Convergent

At time of placement, no payment had been processed on the claim. In the course of pursuing this matter with the carrier, Convergent confirmed that the claim was under Arizona jurisdiction. Unlike Nevada,…
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Dealing with Refund Claim Demands

How our healthcare attorneys stopped a refund demand and saved our hospital client’s money.

An account that was denied for authorization based on medical necessity was brought to our attention on the last day of the timely filing deadline. Convergent managed to contact the review company and…
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Coding Review Overturns Denial

Convergent successfully appeals denied healthcare claim

A Georgia hospital placed an account with Convergent that had been denied for no authorization. Prior to the procedure, the hospital had checked authorization and was told one was not required for the…
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Denied & Problem Healthcare Claims

Convergent time and again achieves results that hospitals cannot attain on their own.

Many hospitals find themselves with unusual claim problems they are not equipped to solve but can ill afford to let go unpaid.

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Settling Motor Vehicle Accident & Liability Claims

Convergent puts motor vehicle accident & liability claims in the fast lane on the road to recovery

When a Texas hospital placed a motor vehicle accident claim with Convergent, Convergent verified auto insurance could not be pursued for payment.

Another Texas hospital had an account for which neither…
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Convergent Makes Fast Work Out of Workers’ Comp

Convergent attorney-driven approach makes fast work out of workers’ compensation claims

Many hospitals face workers’ compensation claim denials without the expertise or resources necessary to successfully dispute the denials.
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Utilization Review Overturns Experimental Claim Denial

Convergent Overturns Experimental Claim Denial

Blue Shield of California initially denied this claim based on a determination that medical records had been requested but not received. After Convergent confirmed that this medical information had actually…
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Self-Funded Health Plan Pays Up

Convergent obtains full reimbursement from aged claim from exhausted self funded plan original sponsor

Blue Cross denied a hospital’s case after determining that the self-funded plan involved in the case had exhausted its funding, and that no payments could be issued as a result. The case was placed…
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Bill Review/Usual & Customary Denial Success Story

Convergent recovers 80% of large usual and customary under payment

A patient’s self-funded Health Plan did not pay at the full applicable contracted rate due to bill reviews. As a result, significant charge amounts were disallowed, resulting in an underpayment amount…
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High Dollar Workers Compensation Recovery

Convergent’s Legal Department obtained payment in excess of one million dollars on a workers’ compensation case for a client in Texas.

The payer, Gallagher Bassett, had denied the claim on a technical basis, asserting that the primary diagnosis code billed was invalid. Convergent immediately contested the denial, stressing that there…
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