of respondents have experienced an increase in payment denials.

Health plans are increasingly denying provider reimbursement for medically necessary care.

Our survey found that 89% of respondents have experienced an increase in payment denials over the past three years, with 51% having experienced a “significant” increase in denials.

American Hospital Association Survey
December 2020

Commercial Insurance Claims Management

Commercial health insurance is any healthcare policy that is not administered or provided by a government program. There are roughly 6,000 insurance companies under the purview of the National Association of Insurance Commissioners in the United States. Health providers must contract with these insurance carriers and follow the policies and guidelines outlined in their agreements to be paid. These standards generate layers of protocol and policy that must be carefully followed to eventually receive payment for services provided. Our team of Commercial Insurance Claims Specialists command expertise across the gamut of coverage types, rules, and requirements involved in claims processing. Their knowledge spans all commercial carriers, nationwide.

MassHealth Claims Management

Persistent follow-up for prompt and proper payment

Our team of Medicaid Claims Specialists are seasoned experts in resolving denials that prevent payment. If 1,700 reasons aren’t enough, MassHealth has 1,701 Explanation of Benefits (EOB) reasons to suspend or deny a claim. or deny a claim.

Whether an eligibility issue, coding error, or other denial protocol prevents payment, we source the problem quickly and make necessary changes to initiate payment without further delay.

When necessary, we pursue appeal claims with the Final Deadline Appeals Board (FDAB).

Because we are experts in MassHealth regulation and procedure, we are eminently prepared to:

  • Resolve issues specific to inpatient and outpatient services
  • Investigate and resolve Medicaid Eligibility Verification issues
  • Pursue payment and coordinate eligibility, which may include split payments between MassHealth and its managed care organizations: Neighborhood Health Plan, Network Health, BMC HealthNet, and Fallon Community Health Plan
  • Resolve issues surrounding dual diagnosis claims (e.g., medical vs.  psychiatric/substance abuse)
  • Pursue prior authorization issues and secure authorizations and approvals retroactively for emergency services
  • Retrieve and provide medical records to the Office of Medicaid, when appropriate
  • Ensure consistency and accuracy of universal billing and claims correction forms
  • Ensure consistency and accuracy of diagnosis and procedure codes
  • Resolve issues with primary care physician/clinician referrals
  • File appeals with the FDAB (Final Deadline Appeal Board)
  • Challenge medical necessity claim denials

Claims Submission
When it comes to MassHealth claims, the bottom line is, “A Clean Claim Gets Paid.” Our claims processing team scrutinizes submissions for likely errors, inconsistencies, and missing data.

Out-of-State Medicaid Claims Management

Every state has specific, exclusive Medicaid laws and regulations, as well the requirement that all healthcare facilities and attending physicians be enrolled in their state payment program. This generates complex layers of protocol that providers must abide by and process to be eligible for payment for services rendered.

Our team of Out-of-State Claims Specialists bring years of experience and expertise to understanding the thousands of rules and requirements associated with Medicaid enrollment and claims processing throughout the United States, ensuring that you are reimbursed appropriately.

Out-of-State Provider Enrollment
The first step in securing payment from out-of-state organizations is to ensure that the healthcare provider and physician are enrolled in the Medicaid agency. PV Kent drives the process by securing all necessary documentation, completing and submitting all provider enrollment applications, and procuring the information needed for all required attachments, including:

  • Certificates of insurance
  • JCAHOs
  • Licenses
  • Completed W-9 forms
  • IRS certifications
  • CLIAs
  • Medicare EOBs (remittance)
  • DEA certifications
  • Board of directors/trustees lists

PV Kent manages out-of-state claims using a well-defined process that involves claims submission, claims tracking and reporting, denials and appeals management, and legal follow-through, as necessary.

Legal Follow-Through
In the rare cases when standard appeals procedures are unsuccessful, our attorneys are available to both advocate and file litigation. These capabilities make us unique in the industry.

Veterans Administration Claims Management

Our Veterans seek and coordinate treatment and services with Veterans Administration providers, or contracted healthcare organizations. So, when non-VA, acute-care hospitals provide emergency services to Veterans, they face a battle to get paid. The Veteran’s Administration (VA) requires medical documentation to verify the nature of the emergency for each claim submitted when there is no contract with a certain hospital. Even then, not all claims are approved for payment. Referring VA claims to PV Kent increases the probability that your hospital will be paid.

Our Claim Services Follow the Same Rigorous Process