Operative Performance Solutions, a division of Operative Enterprise, Inc., is an affiliated consulting firm dedicated to developing efficiency solutions for its clients. The services are closely related to many of the services offered by Hagemeister, Inc. and deserve specific attention. One of those is reimbursement advice.

Reimbursement OPS

That said, we strive to skillfully assist you in making the best possible strategic decisions and in developing “real world” solutions to a broad array of healthcare reimbursement challenges. In every project, our goal is to provide strategies and solutions to maximize your collectible reimbursement.

We also strongly believe that the only viable approach to reimbursement improvement is a collaborative one. In our experience, any real solution must take into account a number of specialized variables and departments, including finance, managed care, government programs, clinical and operations, billing and collection, claims dispute resolution, regulatory compliance and healthcare fraud and abuse law compliance. After considering these variables, the solution must be uniquely tailored to your company, depending on your resources, personnel and practices.

We have worked with some of the most knowledgeable experts and consultants in the healthcare industry and have experienced absolute success with the cross-functional strategic approach. Now, working hand-in-hand with our affiliated consultants, specialists and experts at Operative Performance Solutions, we are able to deliver front-end to back-end solutions on numerous reimbursement projects, including the following:

Comprehensive managed care market analysis. Provider contract due diligence and language/rate analysis. Fraud and abuse exposure analysis. Reimbursement leakage analysis and revenue recovery assistance. Denials management. Contracting policies and procedures. California AB 1455 implementation. Non-contracted policies and procedures. Capitation compensation analysis. Implementation of national contracts. Legislative and regulatory interface. Reimbursement legal training. The reimbursement think tank.

• Comprehensive managed care market analysis. Making good reimbursement decisions starts with a comprehensive understanding of your company and your market’s competitors, employers, providers, and population. This customized report will assist you in identifying opportunities and threats in addition to coordinating reimbursement decisions with operational ones, such as building new programs and expanding existing ones.
• Provider contract due diligence and language/rate analysis. Because most of your commercial business is tied to numerous contracts in various payor categories, we will review your contracts and provide a report on both the potential problems and reimbursement opportunities. We provide these services on a stand-alone basis and in conjunction with healthcare acquisitions and divestitures.
• Fraud and abuse exposure analysis. Does any of your reimbursement originate from a government program, are any of your contracts between hospitals and physician entities or other referral sources? If so, you have significant regulatory compliance exposure. Some of that exposure can be eliminated entirely and the rest can be mitigated with the implementations of appropriate policies, processes and procedures.
• Reimbursement leakage analysis and revenue recovery assistance. In our experience, reimbursement leakage occurs with every type of payor at every stage of the reimbursement process. Much of the leakage is due to a failure to recognize problems and the failure to create processes with regard to contractual, clinical and third-party liability issues. We will review your payment reports, denials data and other related information to determine the source of the reimbursement leakage and develop strategies to minimize that leakage. Then, we are experienced in implementing a broad spectrum of revenue recovery strategies, whether clinical or contractual.
• Denials management. Many denials are characterized by the payors as “contract” denials rather than “clinical” denials. Why is this? Do the payors benefit from this categorization? In any event, we will investigate the true reason for these denials and develop policies and procedures to minimize or eliminate them.
• Contracting policies and procedures. To the extent that problems are identified, we will develop customized policies and procedures to determine necessary provisions, fallback positions and other important concepts to minimize problems in future contracts.
• California AB 1455 implementation. We have considerable experience understanding California’s regulatory scheme and will assist you in understanding the laws and regulations related to managed care, claims processing and adjudication. We will also develop policies to ensure compliance and track your performance.
• Non-contracted policies and procedures. The non-contracted situations are not as simple as they used to be for both providers and payors. While the expectation of full billed charges may not be reasonable, there is little guidance on what a provider should expect in both the government payor and commercial context. And if the provider receives payment that does not meet that expectation, what happens next? We will develop a comprehensive policy and procedure and other related documents for handling non-contracted situations based on applicable laws, your operations strategies and your collections concerns.
• Capitation compensation analysis. The capitation methodology is alive and well in the senior context and may be a good alternative in the commercial context. This, of course, depends on a number of factors, including the size of the payor, the payor’s past payment behavior, the nature of the population, the amount of capitation payment and the competition’s rates, to name a few. We will give you tools to compare the capitation methodology with viable market alternatives and the estimate the potential financial impact of your alternatives.
• Implementation of national contracts. Some commercial payors are encouraging providers to accept a nationally negotiated contract form. However, because each state has its own laws and regulations ranging from licensing to the provision of services to claims adjudication, these national contracts still need to be revised to conform with state law.
• Legislative and regulatory interface. At times, the most efficient solution is to address your reimbursement grievance with the appropriate regulatory authority. We will assist you in developing this strategy and guide you through the process. In addition, it may make sense to object to certain laws before they are passed, we will work with you and our associated lobbyists to make sure your voice is heard.
• Reimbursement legal training. With all of the new laws and regulations affecting both providers and payors and all of the complex reimbursement scenarios, you may desire scheduled and periodic training to update yourself and your staff. We are experienced in providing this training on a broad variety of topics.
• The reimbursement think tank. Do you believe that you are doing all you can to maximize your collectible reimbursement, minimize payment leakage and reduce regulatory compliance risk? If you are, well done! If you believe that there may be room for improvement, we have access to a cross-functional team of reimbursement experts to discuss your practices and expose the various opportunities for improvement.