Our Process

claims-enforcement

Claims Enforcement.

Our client exclusive division was designed to quickly bring non-compliance issues to the attention of third party payors, such as:

  • Timely filing denials
  • Underpayments
  • Medical necessity denials
  • Untimely objection and/or reimbursement
  • Retroactive denials
  • Not automatically including interest with late payments
  • Denying emergency covered services as unauthorized
  • Post-stabilization denials or failure to timely authorize services
  • Repeated requests for insignificant information as a tactic for delaying claims payments AND MANY MORE.

TRAF does not accept self-pay accounts. We specialize in insurance claim reimbursement to compliment and work in cooperation with your existing collection agency. This enables you even larger amounts of revenue to increase your monthly net income.

case-intake

Case Intake.

TRAF conducts self-assessments of its offices to determine whether they “have in place appropriate administrative, technical, and physical safeguards to protect the privacy of the protected health information (PHI) pursuant to 45 C.F.R 164.530 (c).”

Cases can be submitted electronically or by disk (password protected) in .xls or .txt format. Once uploaded (normally two (2) working days), then:

  1. Accounts are assigned to a Claims Compliance Auditor who sends out a ten (10) day compliance audit demand or enforcement letter to Plan Compliance Officer or Director of Claims on file for the payor.
  2. A TRAF Auditor reviews your cases to locate any administrative/prompt payment laws that further support your appeal or demand position.
  3. A compliance call is made to the payor on your behalf to redress any indicated violations.
  4. If compliance (payment details or self-initiated remediation of the case) is not received by the payor within the above timeframe, we submit a five (5) day “Notice of Intent to File Complaint” to the payor.
  5. If no response, a formal complaint (if a previous appeal was made) is filed and weekly calls are made to the payor to see if the case has been resolved to withdraw our complaint.
  6. If payor is not compliant, we allow the appropriate regulatory agency to decide the matter and if necessary escalate the matter to administrative law judge, third-party reviewer or attorney to pursue legal and equitable remedies.
  7. If our representation efforts result in payment of the claim, plus the appropriate interest, the case is closed, reported to you and archived.

reporting

Reporting.

Status reports are sent out monthly. Members receive:

  1. A Monthly STATUS Report-A report of all cases still being actively worked in our office with the last status and/or violation type.
  2. A Monthly CLOSED CASE REPORT-A report of all cases closed by us or you and no longer being worked AND
  3. A Monthly SELF-PAY AGENCY Report-A report of all accounts closed after claims payment compliance with a patient balance owing.

Fees.

Our fees are some of the lowest and our recovery rates are among the highest.

We are so confident in our regulatory claims representation program, that under our contingency model, if there is no recovery made, you pay nothing!

 

Contact us today to start your enforcement campaign.