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Our objective in the Client Services Department is to resolve all inquiries in a prompt and professional manner. Inquiries are expected and our goal is to accomplish settlements to the maximum benefit of our client in the most efficient amount of time. Our Client Services Department is successful in addressing any provider argument consistently, effectively, and leaving no room for provider interpretation on who is driving the appeal to resolution. A Client Support Resolution Process set of procedures has been established and is proven in achieving our objectives.
Client Support Resolution Process
The Client Support Resolution Process (CSRP) is a fundamental step in our Medical Bill Verification process. This step is where the savings achieved for our clients are preserved.
The CSRP is customized to meet every client’s needs depending on their products such as group health (self-insured or fully insured), Individual Policies, Worker’s Comp, HMO Plans, MGU, and Stop Loss, etc. An implementation meeting is held with the client to identify their resolution preferences.
The CSRP is embedded into clients’ appeals processes and the Client Services Department works in conjunction with a client’s appeals unit.
Verbal Appeals
In the unlikely event of a verbal appeal, we contact providers to explain review results and the justification for each reduction. A good percentage of the time, the provider accepts the justification and does not file a written appeal or take any other action.
Written Appeals
Written appeals are forwarded to Hopewell Risk along with accompanying documentation, including plan language. We review plan language and draft the appropriate response.
We will inform providers that they should specify the reasons for each item that they are appealing and supply supporting documentation as appropriate. Providers are immediately informed that generally, a health plan can only review information submitted to them on appeal.
Our experience demonstrates that providers will often recognize that they have billed items in error or that they do not have a justification to support an appeal.
In some circumstances we may inform a provider that historically, providers have only been able to substantiate 27% of denied charges due to the absence of sufficient information or documentation and the appeal must be resolved outside of a formal appeal.
Benefits
Reduced administrative burden upon TPA
A second set of eyes to improve compliance with plan document
Increased retention of identified savings
Our Client Services Account Executives will conduct a courtesy call to the member and validate if they have received communication from the provider.
The member is educated regarding the billing issues identified on their claim and are reassured of our resolution process.
Client Services Account Executives assist the member by providing our contact information for them to refer calls from the providers or collectors directly to Hopewell Medical Bill Verification. We assist the member in writing a dispute letter that will be sent to the provider requesting that they place the account in a dispute status.
A Patient Advocacy Program packet of information is mailed to the member with additional information from the Federal Trade Commission detailing their rights when disputing a debt.
Our Patient Advocacy Program is designed to assist the patient/insured with their account if they have been balanced billed by the provider.
