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Complex Claims Services 2020
Bringing Knowledge and Skills to the Claims Market
Author
Boyd Stewart
Author
Alex McIntosh
Some healthcare claims are harder to manage than others—in particular, out-of-state Medicaid, motor vehicle accident, VA, and workers’ compensation claims. In order to focus their resources on other claims, provider organizations often contract on a contingency basis with specialized firms who have ample experience handling one or more of these complex claim types. Typically, these firms achieve higher paid-claim rates and cash recovery than organizations would on their own. This report is meant to help provider organizations find the right firm for them by examining which firms manage which types of claims and how well each firm performs for clients.
Potential 2020 Rise in Out-of-State Medicaid Claims: Amid the spread of the COVID-19 virus, multiple news sources (including the Washington Post and the Wall Street Journal) report that in an effort to avoid infection, millions of people are leaving states with high infection rates. As a result, coming months could see a steep rise in out-of-state claims, including for Medicaid.
What Firms Do Is Just as Important as How Well They Do It—Few Apples-to-Apples Comparisons
While each firm in this report manages complex claims, it is somewhat unhelpful to compare them side by side because they tend to specialize in one or two types of claims. Each type of complex claim requires different skills, knowledge, and tools to manage effectively.
The table below shows the types of complex claims KLAS has validated for each firm, including what percentage of respondents have leveraged a firm for each type and a brief description of the firm’s performance.
Wide Variation in Overall Customer Experience: Revecore Leads Generally High-Performing Market; Kemberton Lags Behind
Among measured firms, Revecore leads in overall customer satisfaction, working closely with clients to substantially increase revenue and create a feeling of mutual trust between client and firm. This trust is due to the firm’s employees, who are empowered to independently solve client issues and strategically identify changes that could make the claims process easier and increase collections. Clients of Kemberton Healthcare Services report highly variable experiences. Half of respondents are satisfied (with 40% being highly satisfied) and feel their account managers help them be successful. The other half are dissatisfied, citing ineffective communication with the firm, difficulty collecting revenue, and lack of follow-through on expectations set during the initial contracting phases; clients feel they have to continually hold Kemberton accountable in order for the firm to meet agreed-upon expectations.
Revecore, Aspirion, and Argos Health Partner with Clients beyond Simply Working Complex Claims
Argos Health: 92.3
Firm-Provided Information
For Argos Health’s full response, see full report.
History in healthcare revenue cycle:
- Formed in 2017 with plan to bring together experts in all complex claim areas
- Brought together premier providers, each with over 10 years of experience
How our approach is unique:
- Stayed true to complex claims—haven’t diversified to general revenue cycle
- More than a decade delivering these services—clients are truly engaging experts
Acquisitions in last two years & their results:
- In 2019, acquired Caid Solutions (out-of-state Medicaid); led to dramatic growth in use of this service among customer base
Other services besides complex claims services:
- None
Argos Health has helped customers find additional sources of revenue through accounts that customers thought were dead or closed. The firm effectively utilizes their technology and industry knowledge to increase client collections and incoming revenue. They also advise customers on changes they could make to more effectively bring in owed revenue. Clients say Argos Health has been able to find where customers were underpaid for certain procedures or treatments and then go after that revenue to make sure providers are paid what they are owed.
In 2019, Argos Health acquired Caid Solutions. Clients who transitioned from Caid Solutions to Argos Health say that the move was uneventful and that the high level of service they were accustomed to remained consistent throughout the acquisition. Among Argos Health’s general client base, some customers report they had a rough start with the firm, with some system kinks that had to be worked out. However, after some time, these issues were resolved, and their satisfaction improved; today they report high value and high satisfaction from Argos Health’s complex claims services.
“We have definitely received our money’s worth because of the vendor’s integrity. Before the vendor came on board, we were getting little to no payment for certain claims. We didn’t realize how much we were missing out on until Argos Health brought the situation to our attention. We have created a process so that once Argos Health gets the information, they go after patients and ask about who should be contacted. The vendor does the legwork. Argos Health has exceeded our expectations, and I would recommend them to others. Argos Health is very approachable and easy to talk to. They speak in layman’s terms.” —Business office manager
“We had a slow start with the vendor, and that was very frustrating because they couldn’t quite seem to get our system figured out. But we finally got the kinks worked out, and now everything seems to be going fine. We really haven’t had any problems with Argos Health. They are very good communicators. If we do have any problems, the vendor handles those very well. We run through whatever the issue is, and they usually correct it so that we don’t have the issue again going forward. The vendor is pretty good to work with.” —Business office director
Aspirion: 93.1
Firm-Provided Information
For Aspirion’s full response, see full report.
History in healthcare revenue cycle:
- Operating since 2008, with clients in 41 states (new states added each quarter)
- Focused on most complex segment of US reimbursement
How our approach is unique:
- Heavy technology investments
- Never collect from patients (no conflicts of interest)
- Work all claims, don’t cherry-pick
- Focus on client training
Acquisitions in last two years & their results:
- Aspirion formed from combination of best-of-breed Aspirion Health Resources, HRS Erase, & Specialized Healthcare Partners to create comprehensive suite
- Scale has allowed re-platforming technology to produce unique results
Other services besides complex claims services:
- Denials
- Supports not only hospital systems but also several large RCM business process outsourcing providers as a subcontractor
Multiple Aspirion clients describe the firm as “part of [the] team”—they feel the firm goes above and beyond their contract both in helping collect owed revenue and in training organization personnel to increase efficiencies and implement practices that will lead to higher collection rates. Respondents using Aspirion have seen increased collections since going live with the firm, a tangible result that makes the cost of the firm well worth it. Communication with clients is strong, as is executive communication when it is needed; however, executive intervention is rarely necessary because of well-trained, knowledgeable frontline employees who ensure few major problems arise. Proactive communication is a high point for many clients, who say Aspirion proactively reaches out to them to share information about changing requirements or best practices to help improve collections.
“If I don’t like a vendor, I don’t use them. We get a great value with Aspirion, and they have worked with us. They have been flexible with their rates, and we really appreciate that. They have done a phenomenal job for us, and their work shows in our A/R days. I recommend the vendor to people all the time.” —Business office director
“Aspirion is extremely easy to work with, and that isn’t always the case with vendors. Aspirion’s accessibility is more valuable than it sounds. The vendor is easy to communicate with, and they have access to our system, so the process is smooth. They come on-site and are always available for questions. They also provide training to make sure everyone has the needed information. With payers being so regulated and driven by constantly changing policies, there is no way that we could keep up with them. Having someone that we trust who can keep up with the changes is nice. Whenever we get a bulletin, we send it to Aspirion, but they are always 10 steps ahead of us. We have a lot of confidence in them. We don’t use a lot of vendors because we have found a lot of issues with other vendors, but we really like Aspirion. They have done a great job for us, and we have been really pleased with them.” —Business office director
Bolder Healthcare Solutions: 87.9*
*Limited data
Firm-Provided Information
Bolder Healthcare Solutions declined to participate in this research.
Bolder Healthcare Solutions generally delivers a positive experience to clients. However, they have the second-lowest overall score in this research, in part because of a single dissatisfied client who moved to Bolder Healthcare as part of an acquisition a few years ago. This organization appears to have been dissatisfied before the acquisition and to have seen little change in their experience; this client feels the firm has not been as aggressive as they would like in going after revenue and collections and has not lived up to expectations around communication. Other clients also mention the high number of acquisitions Bolder Healthcare has gone through, and one mentioned being tired of the constant changes. Other clients express frustration with communication issues (some acquisition related), leading to unresolved problems and low satisfaction with executive involvement.
When it comes to complex claims expertise, clients generally feel that Bolder Healthcare personnel are knowledgeable about the claims they are handling. Clients who know their customer success manager are very satisfied with their experience, and these respondents say this leads to high satisfaction overall with Bolder Healthcare and their services. Clients also report that Bolder Healthcare is great at finding money in accounts that clients thought were dead, and this has led to improved revenue flow.
“Bolder Healthcare Solutions has gone through a few acquisitions and mergers with Avectus Healthcare Solutions and Cognizant, so things have changed from a staffing perspective. We just have to get used to the individuals who now oversee our account and work with us. Cognizant is going to be acquired at some point, and then we won’t know who our support people are again. At this point, I don’t even know who our representative is.” —Business office director
“We love Bolder Healthcare Solutions, and that is why we have been with them for so long and through many acquisitions. Cassie Henson is one of their VPs and is very involved. We have executive involvement with our accounts and claims, and the vendor truly represents us. We have had a positive working relationship with the executives at Bolder Healthcare Solutions. Cassie Henson has been one of the reasons why we have continued with the vendor for so long. We have stuck with them because of the way they treat us as a client.” —VP of business office
EnableComp
Insufficient data to share performance
Firm-Provided Information
For EnableComp’s full response, see full report.
History in healthcare revenue cycle:
- Manage claim life cycle
- Since 2000, have developed deep context expertise for workers’ compensation, MVA, and VA claims
- Partner with over 800 healthcare providers
How our approach is unique:
- Leading-edge proprietary technology & incorporated rules engine
- Automated workflow & processes
- Expert staff of clinicians and A/R resolution specialists
- Data-driven analytics and state & federal relationships
- Key focus is yield improvement and decreased operating expenses
Acquisitions in last two years & their results:
- No acquisitions in last two years
- Focused entirely on complex claims resolution
- Potentially would pursue future acquisitions of companies that support & augment current portfolio
Other services besides complex claims services:
- All offered functionality is in the complex claims universe; includes zero-balance review, aged A/R liquidation, legacy A/R resolution, denials management, PPO network analysis, payer settlement negotiations, and select prior authorizations
Insights on EnableComp and their complex claims services are based on a limited sampling of clients. The four respondents in this research report they were able to get up and running with the firm quickly. They describe EnableComp’s reporting as helpful and say communication with account managers is strong. EnableComp is also good at driving tangible outcomes (e.g., increased revenue, efficiency).
Insufficient data to show EnableComp Customer Experience Pillar scores
Kemberton Healthcare Services: 74.5
Firm-Provided Information
For Kemberton Healthcare Services’ full response, see full report.
History in healthcare revenue cycle:
- 25+ years as leader in specialized RCM, leveraging expertise and technology to tackle most complex coverage scenarios
- Portfolio has grown (resolution of denied, liability, and VA claims; patient assistance for disability, eligibility, or enrollment)
How our approach is unique:
- Specialized experts help providers and patients navigate labyrinth of payers and benefits
- Personalized advocacy for happier patients and better financial outcomes
Acquisitions in last two years & their results:
- Combined with PRN in October 2018 and APA in October 2019
- Integrated offering; draws on best practices from all organizations
Other services besides complex claims services:
- Guide patients through various health insurance programs
- Comprehensive approach to disability eligibility provides a streamlined patient experience
Kemberton Healthcare Services is the lowest-performing firm in the complex claims space. Clients are highly divided in their satisfaction; about half rate the firm very high, and about half rate the firm low or very low.
Kemberton clients who are satisfied have achieved satisfactory results and feel the firm has the skills and knowledge needed to navigate through complex hurdles and get claims paid. These clients usually point to a working contact or account manager with whom they have built a good relationship over time; these contacts are helpful at solving issues, answering questions, and building confidence in the firm’s abilities.
The gap between satisfied and dissatisfied clients appears to be centered around the firm’s communication. Dissatisfied clients say Kemberton does not communicate effectively and has fallen short on responding to and resolving issues, making it difficult to form a successful partnership. Overall, larger customers are less satisfied than their smaller peers; clients with over 250 beds rate the firm about 12 points lower (out of 100) than organizations with less than 250 beds, and higher bed size is correlated with lower ratings.
“Kemberton Healthcare Services supports us and has good people, and good people are important. My point of contact has actually become a friend; we have more than just a vendor-client relationship. We are lucky to have Kemberton to support us. Sometimes there are bumps in the road, and sometimes we need a push, and the vendor provides that. I couldn’t be happier with the vendor. I would recommend them to any hospital.” —Business office director
“When we express our concerns to Kemberton Healthcare Services, they tell us that they will look into our concerns and do this and that, but things don’t change. There are issues that the vendor hasn’t addressed for years; that is how bad things are. The vendor is picking and choosing what claims they want to work. We haven’t met anyone from the Kemberton side; and we deal only with the people from the acquired PRN company. Those people are very nice and respectful, but the way they handle their claims is frustrating and not impressive at all. We just keep trudging forward. We don’t receive our money’s worth from Kemberton because of our patchy relationship. We would probably be paying more per claim with another vendor, but Kemberton is getting credit for the work my staff members are doing anyway. That situation is frustrating, and I don’t like it at all.” —Business office manager
Revecore: 96.5
Firm-Provided Information
For Revecore's full response, see full report.
History in healthcare revenue cycle:
- MRA|Revecore focused exclusively on MVA & workers’ compensation claims for 21 years
- Nation’s leading submitter of medical claims to property and casualty insurance industry
- Partner with 500 hospitals, processed more than $13 billion since inception, deliver more than $1.5 billion per year
How our approach is unique:
- Automated approach with HFMA Peer Reviewed AcciClaim technology
- Suite of staff attorneys, detailed reporting, and focus on service
- Eliminate hospitals’ administrative burden while quickly resolving all accident claims
Acquisitions in last two years & their results:
- No acquisitions, though in 2018, Riverside Partners strategically aligned MRA|Revecore and BLS|Revecore to provide one-stop shopping; delivery operations remain independent but are a shared services organization
Other services besides complex claims services:
- Revenue recovery for underpayments/payment compliance, DRG validation, transfer DRG, and denials prevention and recovery (through BLS|Revecore)
A standout percentage of interviewed Revecore clients say the firm’s services have substantially increased the organization’s cash flow/revenue. Revecore is the only firm in this report to have 100% of respondents say the firm exceeds their expectations. This creates strong relationships with clients, who often describe the firm as a partner. Revecore sends personnel on-site to train client organizations and help them learn how best to handle complex claims to ensure they are paid. Customer success managers assigned to client accounts are also well trained, knowledgeable, proactive, and personable. Several respondents describe Revecore as the expert in their field. Overall, Revecore clients are highly satisfied with their experience and likely to recommend Revecore to peers.
“Our reimbursements have literally doubled since we have started using Revecore’s services. The vendor has experts. When we were doing things in-house, insurance companies would offer to pay us a 30% reimbursement rate, and we would have to take that. We would try to fight, but we would never get any further. Revecore is getting an 80%–90% reimbursement rate, and they are very quick. We didn’t know some of the rules, but Revecore has done a really good job.” —Business office director
“Revecore has just been phenomenal. We had a wonderful implementation; everything was lined up, and the vendor had everything spelled out in a Word document. We have regular conference calls with Revecore, and they are responsive to our questions. Our representative usually responds within the same day; even when our representative shouldn’t be working, that person responds. Revecore answers all of our questions and is very helpful. If we get a denial, Revecore will promptly reach out and try to get us a letter of documentation to fight the denial.” —Business office manager
Writer
Amanda Wind Smith
Designer
Jess Wallace-Simpson
This material is copyrighted. Any organization gaining unauthorized access to this report will be liable to compensate KLAS for the full retail price. Please see the KLAS DATA USE POLICY for information regarding use of this report. © 2024 KLAS Research, LLC. All Rights Reserved. NOTE: Performance scores may change significantly when including newly interviewed provider organizations, especially when added to a smaller sample size like in emerging markets with a small number of live clients. The findings presented are not meant to be conclusive data for an entire client base.