Medicaid OPWDD Billing Expertise at a $40M Health Care Facility

Client: Large Nonprofit Health Care Facility
Requirement: Consulting

Business Situation:

The client is a 501(c)(3) not for profit agency that specializes in creating opportunities to further the independence of people with intellectual and/or developmental disabilities. These services include, but are not limited to providing Speech Therapy, Occupational Therapy, Nutritional Counseling, Social Work Services and Physical Therapy. Due to changes in staffing and training issues, our client was faced with a high percent of both denied Medicaid claims and receivables over 90 days, as well as multiple claims that were never received by appropriate insurance carriers.

ProNexus Solution:

In September 2019, ProNexus was engaged by the client to assist with the billing & adjudication (of denials) of a backlog of Article 16 Clinic claims. In conjunction with this, we also evaluated existing processes and procedures and recommended changes as needed. ProNexus assigned a consultant with extensive healthcare industry experience across all lines of service and all insurance carriers. Starting with the oldest claims first, ProNexus reviewed and submitted for processing all aged claims as well as provided insight into processing errors that were increasing the frequency and volume of denials and unpaid claims. After 30 days all outstanding 2018 dates of service were reworked, 36% of the claims were identified as over filing limit and another 15% had already been resolved. At that time the engagement was expanded to review the first 8 months of 2019. After a 10-week engagement, 45% of the claims had payment received, 30% were identified as over filing limit and 25% remained in process.

As a result of the engagement, to date the client has recovered $199,500 in Medicaid revenues with an additional Medicaid appeal pending for $97,000 in claims over the filing limit. If the appeal is approved, we will have successfully recovered over $296,500! Additionally, multiple process improvements were recommended & implemented to the billing process to reduce the incidence of future denied claims.

Post by Kaitlin Alfvin

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