Revenue Recovery & Contract Management: Outsource or DIY?

On 29th Nov 2018
Outsource or diy

Healthcare Contract Management & Revenue Recovery

When it comes to money that is lost to claim underpayments and denials, healthcare revenue recovery is the watchword. Underpayments and denials sap precious revenue dollars that providers have rightly earned. The good news is that healthcare contract management & revenue recovery systems, either outsourced or DIY, if the right software, can solve the problem.

It’s time to solve a costly problem.

Healthcare Financial Management Association (HFMA) statistics show the extent of the underpayments and denials management problem:  

  • Underpaid claims average 7-11%

  • It costs an average of $25 to re-work each underpayment and/or denial

  • Denied claims average 5 to 10% or more

  • Approximately 65% of denied claims go unresolved

The Medical Group Management Association reports that only 35% of medical groups appeal denied claims. That is a lot of revenue left on the table.

The Status Quo Doesn’t Need to Exist  

The Healthcare Financial Management Association(HFMA) says that a 5 to 10 percent denial rate is the industry standard, but we don’t believe that status quo is acceptable. We believe it is possible to achieve one hundred percent claims collections across all payers. It requires advanced healthcare contract management and modeling technology, whether you outsource or DIY, to automate claims and analyze reimbursements. A good healthcare contract management system includes contract modeling and reimbursement calculators to accommodate all managed care along with Medicare, Medicaid, worker’s compensation and other government fee schedules and regulations.

Contract management and modeling systems should include calculators for:

  • Value-based reimbursement

  • Tiered allowances for multiple charges in one encounter

  • Reimbursement for multiple codes, length of stay, discharge codes and more

In other words, all providers and healthcare organizations can take control of underpayments and denials, prevent them before they occur, capture every contracted dime and reduce denial rates.  

Identify and resolve internal issues

Doing a payment review and recovery, whether it is Outsourced or “Do It Yourself” will help your facility identify and resolve internal issues.

It is recommended to always use a healthcare contract management software for payment review and recovery. A good system will help you know the status of, or reasons for, underpayments and denials. Software systems can automatically research and resolve claims-related issues to maximize payment.

If your practice has old technology with limited functionality you might not be able to sort claims by underpayment and denial types, including eligibility, documentation, coding, duplicate claims, or medical necessity edits. These are important features. Look for a vendor and software platform that will automatically sort claims and route them to the appropriate resource for correction and resubmission, eliminating manual workflow.

Outsourcing and DIY bring great technology to your door  

The best systems offer a mobile app with transparency and data-based insights into collected versus collectible (CvC). CvC is cash actually collected compared to cash that should have been collected based on payer contracts. When CvC is available, revenue cycle leaders can monitor their collected vs. collectable with reporting to identify where underpayments and denials revenue leakage occurs by payer, physician, denial reason etc.

Look for technology platforms known as software-as-a-service (SaaS) solutions. It eliminates the need for organizations to purchase, install, maintain and upgrade the solutions, which consumes vital resources. They are also highly scalable and cost effective.

It’s all about managing resources wisely

A careful determination of when to handle tasks internally or outsource is part of fiscal responsibility and resource management. Outsourced vendors and advanced DIY software can find lost revenue and rope it in. The result is a healthier bottom line and more efficient use of resources that benefit the healthcare organization as a whole.

About Revenue Masters™

Revenue Masters is a leading provider of cloud revenue cycle technology and reimbursement services. We offer you 3 options for simplified denials and underpayments revenue recovery:

  1. Full Service. No cost unless your claims are reimbursed with full transparency.

  2. Do It Yourself. Use our intuitive payer contract modeling and management SaaS and run a complete underpayments and denials management system.

  3. Hybrid. No cost unless your claims are reimbursed and switch to DIY when you are ready.

With a state of the art payer contract modeling and management software aligned with underpayments and denials recovery as a service, Revenue Masters is helping providers bottom line and peace of mind that they are collecting every dollar they earned per their payer contracts.

For more information about our healthcare contract management software, and our 3 revenue recovery options, download our white paper here, email us at or call us at (877) 591-2590