Claims Representation Unit

You advocate for medically appropriate healthcare.

Everything we do, you do.

When you use our regulatory claims representation services, our voice is strengthened to fight violations of public health and safety and ensure your compliance to “advocate for medically necessary care” in your state.

“To advocate for medically appropriate health care” means, (1) to appeal a payor’s decision to deny payment for a service pursuant to the plan’s grievance or appeal procedure or (2) to protest a decision or policy that the physician reasonably believes impairs the physician’s ability to provide medically appropriate care to his or her patients. (CA B&P Code § 510)

Even with the most sophisticated Patient Financial Services process in place and the most powerful A/R strategy to reduce days, many patient accounts are going to exceed the statutory timeframe for prompt payment, and be improperly denied and remain unpaid.

With an unprecedented 50% of the nation’s hospitals losing money from operations (Thomson Reuters), The Reimbursement Advocacy Firm (TRAF) helps providers keep their doors open, ensuring patient access to critical trauma and medically necessary care.

TRAF redresses power inequitites that exist between health plans and providers. Our legislative voice and presence in the healthcare industy has allowed us to create a revolutionary division at the increasing demand of clients who want a fresh alternative to the “conventional” collection agency.

We combine a proprietary appeal process (compliance demands and affidavits) with a regulatory advocacy group presence to:

  • Help enforce timely reimbursement as required by State and Federal law
  • Speed up your cash flow
  • Escalate unresolved claims or problem payors to Federal and State regulatory agencies
  • Reduce bad debt and A/R days
  • Establish your facility with a strong reputation for challenging improper denials and unfair payment practices.

Citing regulatory statutes and cases in the appeal and revenue process is the most effective way to stop unfair payment practices, overturn improper denials and ensure timely reimbursement.

Third party payors process a huge volume of accounts, delaying and denying payment on thousands of claims every year. They do this knowing that most of their inconsistent practices are accepted without quesiton or action; knowing that most medical providers do not have the time and legal expertise to investigate the basis—or lack thereof—of claim delays and denials.

WE CAN HELP.

Our presence will help you instill preventive measures to encourage third party payors to voluntarily adjust their practices to come into compliance with applicable state and federal laws.

NOTE: As members of NCRA, we suggest you “investigate, evaluate and rate the third party law firms and vendors that you plan to use just as carefully as you do when you choose employees.” You want a partner that will work with you to understand your provider needs and truly escalate cases to the next level.

ASK YOUR VENDOR:

  • How do you escalate matters if recovery is not successful?
  • How many regulatory complaints did you file last year?
  • What is your legal appeal position for overturning Timely Filing, Retroactive Denials, IPA Payment Failures, Underpayments, etc.?

We are the referral center for the toughest denials.

 

CALL OUR CLAIMS REPRESENTATION HOTLINE NUMBER:
(714) 995-6900 ext. 6935, TODAY!

Contact us today to start your enforcement campaign.