Medicaid Outlier Revenue Enhancement (MORE)

Cain & Associates

The Medicaid Outlier Revenue Enhancement recovers lost Medicaid revenues and identifies much-needed opportunities for health care providers to improve their bottom lines.

The Medicaid Outlier Revenue Enhancement, a Cain & Associates product, identifies Medicaid inpatient accounts that qualify for Medicaid outlier reimbursement, thus recouping lost Medicaid revenue. MORE insures that hospitals receive the level of payment that they are entitled to for Medicaid-eligible patients. C&A uses state-specific algorithms along with a proprietary process to accomplish an end result that can put millions back into a hospital. There are no upfront costs—fees are contingency based.

Cain & Associates Medicaid Outlier re-billing process is straightforward:

Hospital sends electronic data file of all Medicaid claims to C&A through secure information exchange;
C&A analyzes the data to determine claims that qualify as Medicaid Outliers and returns electronic file of qualifying claims to hospital;
Hospital re-bills Outlier claims to the state Medicaid program, and identifies the account as a C&A account; and
State Medicaid program adjudicates Outlier claims submitted and sends additional payment to the hospital.

C&A’s expert team of utilization review nurses and physicians review the clinical documentation that supports the claims and handles the entire administrative process related to IPRO. C&A tracks all claims at every stage of the process and provides the hospital with status reports.

Additionally, C&A performs a six year retrospective review on Medicaid inpatient claims and a two year retrospective on Medicaid Managed Care inpatient claims.

In 2000, Cain and Associates began working with hospitals around the country, recovering more than $20 million in lost revenue for their clients. C&A is currently serving clients in New York, Virginia, Maryland, South Carolina, Ohio and Kentucky.