Medical billing and insurance reimbursements are notoriously complex, making it challenging for hospitals and physician practice groups to detect underpayments by insurance carriers, especially when dealing with large volumes of claims. When faced with the suspicion that an insurance carrier might owe money for healthcare claims without the concrete evidence to prove it, the situation can seem insurmountable.
This was the case for Texienne Hospital Systems and Texienne Physician Management Association. Texienne had contracts with four major health insurance providers—Blue Cross, Cigna, United, and Aetna—and suspected significant financial losses on chemotherapy and other life-saving treatments. However, they struggled to find the “smoking gun” amid millions of lines of data, and the age of the claims posed statute of limitations risks.
Texienne engaged us to evaluate their claims and file arbitrations against each major carrier. Leveraging artificial intelligence, we identified millions of dollars in underpayments. Our investigation revealed that some carriers were using deceptive explanations of benefits to mask improper contract interpretations and reimbursement practices. We demonstrated that Texienne could not have been aware of these illicit activities due to the misleading information provided by the carriers.
We also uncovered that certain carriers were submitting misleading and sometimes false remittances, effectively concealing their actual reimbursement practices from hospitals and providers. Our AI-driven analysis showed a significant discrepancy between the carriers’ stated practices and their actual reimbursement actions.
As a result of our efforts, Texienne recovered millions of dollars in underpayments from the four major carriers. Additionally, we successfully litigated out-of-network claims in federal court, further increasing Texienne’s total recovery. In the end, Texienne was able to recover most of the claimed underpayments through multiple arbitrations and lawsuits.
