Since the implementation of the APC payment methodology for the reimbursement of Medicare outpatient procedures, it has been very difficult for hospitals to estimate the expected revenue from outpatient claims. Now other payers, including many Blue Cross plans, are adopting this same complicated payment methodology.

During our 25 years experience at recovering lost charge revenue, we found that outpatient billings typically exhibit higher-than-average rates of charging errors. With the development of sophisticated data mining software to scrub Medicare claims for potential charging errors, we can pursue lost charge recovery on outpatient claims. This proprietary software enables us to examine tens of thousands of outpatient bills and select only those few that have a high probability of a billing error.

Our lost charge recovery experts review the selected claims and verify the clinical documentation supporting an adjustment. Our experience has shown that while the error rate may be small, the money recovered can be huge.

A five-hospital system asked us to review 78,000 paid outpatient Medicare claims. Our software identified about 3,000 accounts with potential errors. Further investigation narrowed the errors to 469 accounts. Although the error rate was less than 1%, this hospital recovered nearly $500,000 from those few accounts.