Services

FIRM RCM

Our team of dedicated professionals are experts in the significant variety of reimbursement opportunities available to get your claim paid. We advocate for your facility and your patient, and support our arguments with clinical reviews and precedents established in statutory and case law.

From processing daily claims, to supporting high value hospital claims, our team brings a diverse background to the table. Our expertise allows us to advocate for you and your patient, in an efficient and professional manner.

When dealing with complex billing matters and high stakes appeals, make sure that your trusted business partner offers the expertise and resources required to get your claim paid. FIRM offers a comprehensive and highly educated support team of professionals, with a proven track record of success in resolving the most difficult and complicated claim issues.


Attorney Driven Denied Claim Resolution Service

Our Claims Resolution service represents one of FIRM’s most effective specialty offerings. By utilizing InterQual, Case & Statutory Law, and other proprietary techniques developed over the years, FIRM challenges insurance payer denials with unprecedented success.

 

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The results are impressive, and more importantly, the hospital and the patient receive the proper financial consideration and reimbursement for services rendered. Our process allows you to assign single accounts, or batch assignments of multiple accounts.

Workers’ Compensation Billing

Privatization of the Workers Compensation industry, caused an influx of insurance carriers, in response to employers searching for new and cheaper coverage. This resulted in significant confusion about which payers are responsible for paying which claims. Patients are not provided with identification cards and do not know who their carrier should be. Worse yet, neither do a majority of the employers. Without this information, admissions staff is unable to input the correct insurance information, or bill the proper carrier.

To accelerate payment of workers compensation claims, facilities can assign accounts at the time of admission, or as soon as practical, so that FIRM’s staff may initiate the process of obtaining the authorization and maximizing payments. All claims will be verified, claim numbers obtained, and adjustors identified before the claim is billed.

Out-of-State Medicaid Billing

In a declining reimbursement environment, it is imperative to maximize resource utilization, reduce administrative costs and improve patient satisfaction. As a fully integrated extension of a client’s business office, FIRM will provide the specialists and best practice protocols, to effectively implement provider enrollment, treatment authorization (TARs), and billing and follow-up of Out-Of-State Medicaid Claims. Additionally, we will provide your admitting department with reference placards for 24 hour referral instructions.

Third Party Liability & Lien Service

FIRM’s TPL service is designed to assist clients in achieving increased efficiency with their most labor intensive financial class. We offer a full range of third party payer solutions to assist you in maximizing your reimbursement, while coordinating third party payer options.

Our TPL experts will assist you in navigating today’s complex, litigious environment to ensure that you recover the maximum legal amount from the most appropriate payer. We file all types of liens to protect your rights and entitlement to reimbursement for your services.

FIRM routinely files the following types of lines:

  • Hospital liens
  • Standard personal injury liens
  • Creditor claims for probate/estate cases
  • Adversarial estate filings

FIRM has significant expertise in assisting non-profit hospitals meet the requirements of IRS regulation 501r. FIRM provides attorney assisted coordination of accounts meeting the requirements of 501r and the hospitals written financial policy. FIRM coordinates with business office work groups and can assert reimbursement rights on accounts that qualify for charity care.

Medicaid Eligibility

(Primary & Secondary)

Supported by Medical Assistance Specialists with years of experience in providing linkage to entitlement programs, our specialists will pursue all avenues to transition self-pay accounts to Medicaid payable status. We work on-site at your hospital and will develop a schedule and program that ensures we intervene when a self-pay patient is identified. Our staff will work both inpatient and out-patient accounts. As an added benefit and if warranted, FIRM will provide attorney driven appeal functions under our claim resolution service for no additional fee.

Credentialing Service

FIRM offers an easy and cost effective program for streamlining, simplifying, and expediting physician credentialing. Our specialists combine systematic follow-up with proprietary protocols to ensure accurate, timely, primary source verification, and to expedite provider enrollment.

We work with all specialties and assist with enrollment in all insurance networks (Government and Commercial).  We can also assist you with your Medicare provider enrollment and re-validation services. Our service includes:

  • Standardized data collection
  • We complete all forms  for the hospitals signature prior to program submission
  • We perform all follow-up
  • Credentialing and re-credentialing
  • Physician CAQH accounts opened and updated
  • Create significant physician goodwill

Firm Defense Audit Services

FIRM helps you keep more of what you bill. Using highly skilled attorneys and clinicians we provide pre and post payment defense audit services. Our approach includes clinical review referencing InterQual and Milliman (MCG) guidelines; and/or utilization of contract, statutory, and case law in pursuing the defense and or recovery of your reimbursement.

 

DRG Audits

Payers and their recovery contractors send letters stating that a review of the claim indicates that coding does not meet the appropriate criteria for inclusion of a particular diagnosis; and because the criteria are not met the DRG (and the payment amount) are being reduced. While the payers would like facilities to believe that these reviews are a random event related to reviews conducted on all claims; these reviews are anything but random. They are the result of concerted efforts to mine claim data for diagnosis codes that will result in substantial decreases in DRG reimbursement.

The most common diagnosis codes reviewed are sepsis and septicemia, pneumonia, acute kidney injury, respiratory failure, encephalopathy, malnutrition, and electrolyte imbalances. Firm’s experts review your medical record and the associated coding to respond to these data mining efforts, preparing a professional response outlining any relevant ICD-9 / ICD-10 guidelines, specific medical documentation to support the reviewed conditions, and federal, state, and local law regulations to refute these revenue recovery attempts.

 

Outlier Overpayment Recovery Audits

When charges for an inpatient stay meet the threshold for additional payment beyond the base DRG payment (an outlier), payers attempt to exclude many of the charges listed in the patient’s detail hospital billing from the calculation of outlier payments. The payers assert that the charges are routinely covered under the “room and board” umbrella and should not be charges separately.
Firm’s reimbursement audit team will review your medical record, the excluded charges, and respond to each line item of the payment reduction with supporting documentation from payer manuals, state and federal regulations and the medical record to assure that full payment for your services continues to be provided. Firm will also apprise you of any billing procedure errors that may have exposed your facility to these audits so that you may take the necessary remedial steps to correct these issues.

 

RAC Audits

Recovery Audit Contractors (RACs) have been tasked with the responsibility of identifying overpayments in a post-payment review. FIRM has worked to defend these cases from both a legal perspective and a coding/clinical perspective. Post-payment audits target not only Medicare and Medicare Advantage plans but also most Medicaid products. These audits are creating financial unrest with our current providers. In some cases, auditors are requesting recoupment on accounts older than three years and are exceeding their statute of limitations to request the recoupment. FIRM will defend these audits and work closely with both the patient accounting department and the medical record department to develop a process so that timelines are met and unnecessary recoupments are avoided.

 

Zero Balance Audits

FIRM will review zero balance accounts for all payers based on facility specific transaction codes within 12 months from the date of final bill, or to the time limits established by the payer contracts and state/federal regulations (retrospectively). FIRM will review claims for all payers (concurrently) at the time of denial, underpayment, or upon the facilities’ request. FIRM will do a root cause analysis of the identified underpayment or denial. FIRM will determine if the underpayment/denial is due to a technical issue or a medical necessity issue. Based on the root cause analysis, FIRM’s integrated team of attorneys, clinical staff and appeal specialists will work to resolve the underpayment/denial through the allocated appeals process. FIRM’s clinical team is made up of nurses and physicians specialized in providing defense audits of medical care. FIRM’s appeal specialists work closely with the payers to resolve technical denial issues and coordinate the medical necessity appeals. The process is client driven based on the client’s needs.