Switch RCM's Underpayment Detection System takes out the manual work of analyzing past payments for revenue missed due to payor underpayments.
Our Underpayment Detection System is powered by an engine that consumes 835 data and uses machine learning techniques and business logic to determine the expected allowed amount (contract rate) for your common services for your top payors. The process is at least 97% accurate at determining rates within 0.1% of the actual contracted rate.
The Underpayment Detection System can quickly model your contract terms and rates without any manual input or other human intervention, with a high degree of accuracy. In many cases the Underpayment Detection System can create accurate contracts faster than it will take Managed Care Contracting to respond to your email requesting copies of the contracts.
The best part comes next. After self-building the contracts for your top payors, the Underpayment Detection System engine processes the same 835s again to determine what services were likely underpaid and to quantify the likely underpayment amounts.
The results provided are available at an overall summary level and at a level of detail that is sufficient for appealing underpaid claims in bulk or individually. We will compile the data for you into an appeal document using formats we used for successful recovery projects in the past, the format requested by the payor when you notify them of the errors, or on the payor’s proprietary appeal/dispute form.
At this point in the process it is helpful for Switch to get the actual contracts and 837s because often underpayments are due to a configuration error in a payor’s contract system (rather than manual claim adjudication errors). In the case of a configuration error it is important to be able to prove the claims were submitted correctly and point to the specific contract language that shows how the claims should have been paid. This will help the payor identify the core issue on their end that needs to be fixed to prevent future underpayments and to ensure that the reprocessed claims are paid at the correct rates.
After any appeals are submitted Switch then tracks the recovery via 835 data to make sure that your claims are being reprocessed accurately and in a timely manner. Reports will be provided weekly at both the summary and detail level on the progress of the recovery process.
We know this process is successful, but we cannot guarantee success for every client. For this reason, we offer the Underpayment Detection System contract and payment analysis at no risk to you. Even if you want to use Underpayment Detection System to validate your underpayments are under control, that your payors don't underpay you 🤣, that your current contracts vendor or build are catching all opportunities, you can still do so at no risk.
By no risk we mean that if no underpayments are found or the underpayments found are not of significant enough value to pursue (based on your determination, not ours), there is no cost to you beyond the resources used to provide us the 835 and other files for analysis.