2.3 SCOPE OF SERVICES
2.3.1 The CONTRACTOR shall review all of the HOSPITAL’S commercial payer contracts and enter the contract payment terms into its software, for the purpose of modeling what our payments should have been for services delivered over the preceding 12 months.
2.3.2 The HOSPITAL recognizes that payers do not allow the HOSPITAL to go back more than 12 months from the date of final payment or denial, so the period to be reviewed by the CONTRACTOR shall be from the date the audit begins and the preceding 12 months.
2.3.3 In addition to payments from commercial payers, CONTRACTOR shall review payments from governmental payers, such as, but not limited to; Medicare, Medicaid, Tricare, Workers Compensation, as well as Medicare Advantage and Medicaid managed care plans. Claims payments shall be reviewed by the CONTRACTOR for hospital‐owned physician clinic services as well as hospital services. The HOSPITAL uses third‐ party software such as 3M and SSI.
2.3.4 The HOSPITAL will provide the CONTRACTOR access to all claims with a zero‐balance during the period under review. The CONTRACTOR shall compare the payments received on those claims against our payer contract terms. The CONTRACTOR shall review claims in chronological order, beginning with the oldest claim.
2.3.5 The HOSPITAL anticipates the review of a year’s claims is to be completed between four and six months. After the claims have been audited, HOSPITAL and CONTRACTOR will evaluate the need to audit the subsequent year’s claims.
2.3.6 The CONTRACTOR shall re‐process all claims that are found to have been paid incorrectly and work with the payers and the business office to obtain payment. Payments by 3rd party payers will be remitted to the HOSPITAL and a contingency fee will be paid by the HOSPITAL to CONTRACTOR on a monthly basis, based upon cash received by HOSPITAL from 3rd party payers on accounts reprocessed by CONTRACTOR.
2.3.7 HOSPITAL and CONTRACTOR will work together to establish the necessary access to MEDITECH and payer contracts to enable the CONTRACTOR to perform under the terms of this agreement.
2.3.8 Upon full execution of the Agreement by both parties, the CONTRACTOR shall conduct the audit of the previous 12‐month period, and then on a quarterly basis upon receipt of a data file from the HOSPITAL.
2.3.9 The CONTRACTOR shall work with the HOSPITAL’S business office staff to ensure a knowledge transfer surrounding the claims paid improperly. The goal is to ensure that the HOSPITAL’S business office staff implement a review process to ensure that claims are paid properly going forward.
