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Adonis Underpayments Uses Machine Learning To Help Identify And Recover Missing Claims Revenue

Providers, On Average, Are Underpaid 8-11% By Insurers. This Makes it One of the Most Overlooked Areas Of Missed Revenue for Healthcare Organizations.

Identifying the Gap

We’ve made a pretty compelling discovery. After methodically unpacking the revenue cycle of medical practices, PE-backed roll-ups, digital health, and hospital partners, we learned that one of the most overlooked areas of missed revenue is underpayments.

Providers, on average, are underpaid 8-11% by insurers. When more than half of US Hospitals and Healthcare providers are expecting to post a loss in 2022, it's all the more important for institutions to collect the revenue they deserve in order to deliver the highest quality of care.

Underpayments are when the amount reimbursed by an insurer is lower than the expected contracted amount. This typically happens when your billing team prepared a claim that didn’t ask the insurer for the full amount - and turns out the insurer has no obligation to correct this mistake.

Of course, it’s not always the consequence of human error by a billing team. Knowing how much to bill on a claim is very complicated, especially as contracts continue to become more nuanced and harder to negotiate.

Here are some examples of common underpayment patterns:

  • The amount placed on the claim incorrectly maps to a cheaper CPT code
  • Mismatch scope of the fee schedule and the scope of the rendering provider (e.g. the fee schedule providers an M.D. rate and the rendering provider is an N.P.)
  • Billing errors can occur when the CPT or place of service (POS)  code on the claim does not accurately reflect the services rendered and the location where those services occurred.

To address the issue head-on, we build Adonis Underpayments. A solution that applies machine learning to study payer contracts, submitted claims, and reimbursements and automates the appeal process to help you recover missing revenue.

Getting Started with Adonis Underpayments

Adonis starts by seamlessly integrating with your EHR system (we work with dozens of them including AthenaHealth, ModMed, EclinicalWorks, DrChrono, and more), your claims clearinghouse (such as ChangeHealthcare, Availty, MedData), and your existing insurance contract data.

Adonis then does the heavy lifting of monitoring submitted and remitted claims, flags the ones that have a high likelihood of underpayment, and handles all appeals for you.

For existing Adonis users, you can get in touch with your Adonis product support manager to learn more about mitigating underpayments.

If you are new to Adonis, we’d love to hear from you. Feel free to reach out here or schedule time with us here.

Akash Magoon
Verified writer