Blue Cross Blue Shield Revenue Strategies


MICHAEL FELCZAK, JR., MSA
Director, Provider Reimbursement Analytics
810.853.6165
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J Hedges 1686
JIM HEDGES
CPA, CIAP-T, MSCIS
Reimbursement Consultant
810.853.6174

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KIMBERLY SMITH
MSITM
Healthcare Database Analyst
810.853.6166


TAMRA RAAB
Reimbursement Analyst
810.853.6170

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The complexity of the Blue Cross Blue Shield payment process creates the need for a high level of expertise to help obtain appropriate reimbursement levels. The Rybar Group has the knowledge and experience to assist your hospital with this process. Our services are backed by more than 20 years of experience in Blue Cross payment strategy and a firm commitment to ensure that you are receiving the correct Blue Cross payments for your services.

CASH RECONCILIATION AND APPEALS

We have successfully obtained more than $25 million in additional Blue Cross Blue Shield cash settlements for our clients over the past four years. Through a detailed examination of your annual Cash Reconciliation and Front Sheet claims data and adjustments, we identify and document potential appeal issues and provide potential rate model impacts. We work with you through all levels of the appeal process to protect your rights for accurate payment.

CONTRACT PAYMENT / RATE NEGOTIATIONS

We bring years of experience assisting providers in successful rate negotiations with Blue Cross. We analyze all aspects of your financial and statistical data, as well as external factors that impact your operations. This comprehensive analysis provides the supporting documentation necessary throughout the negotiations. We will prove a complete impact analysis of proposed rates to aid in your decision making process.

PAYMENT LOGS AND VALIDATION

The Rybar Group utilizes a data-driven methodology to analyze ANSI 835 files and calculate your proper Blue Cross payments. We will provide you with accurate payment logs throughout your fiscal year which can eliminate your internal manual logging process. The key to receiving accurate Blue Cross payments throughout your fiscal year is the validation of claims data within your ANSI 835 payment voucher files. Our proven methodology allows us to provide you with an accurate breakdown of your inpatient and outpatient services by payment category. This service can be used to validate your contractual amounts, provide support for year-end audits and reconcile BIP Reviews. Our expertise helps you take control of your Blue Cross reimbursement.

PEER GROUP 1 – 4 MODEL REVIEW

An analysis of the full cost model is an integral part of the negotiation process. Our analysis will assist you in understanding the potential impact the model may have on your reimbursement rate. Our Blue Cross team will analyze the data, along with your statistical and financial information, to reveal potential opportunities. Your model is an important factor for rate setting; let us ensure that you have all the information needed to optimize your rates.

PEER GROUP 5 MODEL REVIEW

While Blue Cross payment to Peer Group 5 hospitals may seem simple, the reality is, that it is very complex. The Rybar Group’s team of Blue Cross experts understands the complexities of the Peer Group 5 rate model and will provide you with the knowledge to optimize your reimbursement. We also offer strategic pricing services to provide you with the knowledge to optimize your reimbursement. We provide strategic pricing services to optimize your cash flow while maintaining compliance with your attested price increase.

Is your facility eligible for additional Blue Cross payments? Our review of your statistical and financial information may reveal potential opportunities.

ATTESTATION AUDITS

We successfully defend price attestation-related recovery audits for hospitals of all sizes. Our services include a detailed comparison of Chargemaster-level services, assessment of service line changes, and a comprehensive analysis of volume changes. We will provide you with a complete and accurate calculation of your true price increase. We work with you through all levels of the appeal process to protect your rights for accurate payment.

PAY-FOR-PERFORMACE

The Pay-for-Performance program recognizes hospitals for achievements and improvements in quality and efficiency through additional operating payments. We can assist you in ensuring that you are taking advantage of the quality incentives available to your facility. Through our documentation assessment process and benchmarking of measured outcomes, we can assist you in optimizing this additional revenue opportunity.

CLINICAL AND BILLING AUDITS

Hospitals are subject to various audits by Blue Cross to ensure compliance with its utilization, quality and health-management programs. The Rybar Group has the resources available to assist you with all your Blue Cross audits and reviews.

PRICING STRATEGIES

What is your strategy for developing rational pricing? The state of the economy is making everyone more cost-conscious, from the payors to the patients. We have worked with healthcare financial executives nationwide in performing a comparative analysis of their pricing to their peers and in adopting transparent, justifiable pricing that meets the demands of the organization.

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