NAPA RCM Engine Empowers Health System Client to Recoup $13 Million in Insurance Underpayments

Overview

Anesthesia billing is complicated. Clinician reimbursement rates vary by insurer at national, state, and local levels, creating thousands of variations of expected reimbursements. Contracted rates and clinical modifiers vary by insurer and provider. Policies and processes change regularly. For hospitals and health systems, internally navigating this highly specialized system can be cumbersome and costly.

Problem

A large system overlooked major billing guideline change, resulting in $13M in insurance payor losses

A large Southern health system operating as a private health organization (PHO) manages its own contracts and reimbursement rates with payors. As one of the system’s five anesthesia services providers, NAPA utilized the PHO’s rates for its Revenue Cycle Management (RCM) billing purposes. In 2021 a major insurer changed its billing guidelines to recognize anesthesia modifiers.

This critical change impacted how medical direction is reported and how anesthesia clinicians are enrolled. As a result, the insurer failed to pay 50% of the total insurance claims for anesthesia services at this PHO. Such oversights can contribute to less revenue and higher anesthesia stipends for health systems.

Solution

First to identify the problem

Our robust RCM process and models quickly identified how the insurer’s new protocol was mismanaging reimbursements. Once we alerted the PHO, our RCM team provided data, evidence, and negotiation insights to enable the PHO to approach payors about this situation. The outcome was a reversal of the insurer’s decision and collection on current and retroactive reimbursements.

NAPA’s proven combination of technology and talent enables us to maintain the integrity of contracted anesthesia reimbursement rates with every payor nationwide. In this dynamic healthcare market, maintaining rate integrity is critical to a provider’s ability to thrive—but most billing companies and internal RCM teams at healthcare institutions lack the capacity to ensure that their reimbursement collections are equivalent to expected billings for anesthesia services. NAPA’s specialty expertise and proprietary technology systems help clients ensure they are not losing out on millions of dollars in revenue.

As the national leader in single-specialty anesthesia services for 40 years, NAPA brings exceptional expertise in the clinical and business aspects of anesthesia to our healthcare provider partners. Our proven RCM services have helped multiple hospitals increase collection rates, improve patient satisfaction, and recover multimilliondollar underpayments from insurance payors.