Back in 1999, I landed a job with a medical claims repricing firm. Before that job, I had never worked with medical claims and was unfamiliar with the industry. However, because of my strong work ethic and drive to be successful, I quickly learned everything I could about the company I worked for and the services it provided.
What I learned about my new employer is that they contracted with PPOs to purchase or lease their proprietary contracted rates with healthcare providers and then use that proprietary information to discount/reprice out-of-network claims with in-network rates on behalf of insurance payers who paid a percentage fee for discounts on their out-of-network payable claims.
Thus, I learned that what my employer was doing is dishonest, and right out fraudulent in some cases. It's known in the industry as silent PPO fraud because the PPO is silent in regards to providing any of its contractual obligations like patient steerage, though the insurance payer is still taking a discount without contractual rights under the false pretense that they are contracted with the reimbursed provider through the PPO they used.
I remember getting phone calls from providers who were screaming at me because of how companies like mine were hurting their business with all the improper repricing of their claims. I felt so bad for them, but couldn't do anything because the company refused to rescind any discounts, no matter how invalid they were. I eventually left the repricing firm because I couldn't handle its dirty shenanigans.
After leaving the repricing firm, I started a home-based business as a claims intermediary between health payers and providers conducting settlement negotiations. At first, I thought that I could help providers by providing an honest and upfront way for payers to discount their out-of-network claims without deceiving the providers with silent PPO discounts. But after a few years of only having one client because payers prefer silent PPO discounting over settlement negotiations, I decided to use the information I learned from the repricing firm to help small independent medical providers recover monies from silent PPO discounting of their claims. However, after starting my new business, I soon learned that my provider clients were getting cheated out of their full reimbursements by the insurance payers in many other ways too. So, I decided to help my clients in recovering their rightfully earned full reimbursements the best that I could. And in so doing, I was constantly researching and studying for effective ways to defeat improper denials and underpayments. Needless to say, I made mistakes along the way, but I learned valuable lessons from them. Then I discovered ERISA law and how I might be able to use it for reimbursement recovery. So I began to study it.
Then one day while disputing underpayments with an attorney to a prominent insurance payer, she admitted to me that her company handles thousands of employer-sponsored plans and couldn't keep up with them all, so they just reimbursed claims according to their own policies. I was shocked to hear this. However, this information opened the door to the solution I had been seeking for so long. I knew that I had to learn ERISA law because it governs almost all employer-sponsored plans. So I sought out to learn all that I could about ERISA. And in that quest, I was blessed to have received some training from a couple of ERISA specialists in addition to all the research and study I conducted on my own.
And now, after years of experience with insurance claim resolutions along with continuous research and study in ERISA and other state and federal laws and regulations, along with ruling case law pertaining to health claims and reimbursements; I have developed certain techniques for successfully overturning and collecting on challenging claim denials and underpayments while increasing reimbursements.
However, this is not your typical denial/underpayment recovery service. Most recovery providers only focus on contractual and billing errors for revenue recovery. Few will challenge, much less overturn, payers' reduction/denial policies and tactics, And I'm unaware of any recovery vendors who will compel payers to reimburse their clients fully and correctly on future claims. Moreover, my passion is in helping solo and small practices who I believe need this service the most, and I give special attention to each client's needs. Whereas most other recovery vendors only service hospitals and large group providers, forgetting the little guys.
And I give thanks to God and His guidance in all this. It was Him who gave me the compassion I have for independent medical providers suffering from this systemic problem. And He has guided me in all my quests to learn and grow in this industry so that I can help as many providers as I can, and possibly some day, play a part in restoring this broken industry.
- Kevin Barrett, Reimbursement Specialist / Consultant
