Our Services

NEED IMMEDIATE HELP?

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

Clinical Denial Unit

ERN/NCRA/TRAF offers a Denial Prevention Program and Unit to protect your health care delivery system.

As a trusted name in reimbursement advocacy, we strengthen your voice to redress unfair payment practices with state and federal regulatory agencies.

The Denial Prevention Unit works in concert with your Case Managers to:

Fight prospective care (pre-certification) denials.
Fight concurrent or continuity of care denials and initiate a notice of disagreement of care to trigger the plan’s responsibility to assume care for the patient under Health and Safety Code 1371.4(d.)
Expedite transfer of a patient to ensure continuity of care.
Convert tracking and reference numbers to authorization numbers to avoid denied days (beyond stabilization) for statutorily deemed authorized services.
Challenge a plan’s refusal to conduct a retrospective review for unauthorized medically necessary services (provided after normal business hours, or when the patient’s insurance information was not provided, etc.)
Challenge improper requests for medical records to review services prior to the issuance of an authorization.
Challenge improper denials of care after patient is discharged under Title 28.
Challenge a reduction of level of care or disputed healthcare service under Health and Safety Code 1374.30(b.)

We thrive to exist as an extension of your Case Management and Business Office. We passionately understand the importance of assisting you advocate for medically appropriate healthcare for patients while being properly reimbursed for the services you provide.

IF WE DON’T GET THE AUTHORIZATION NUMBER FOR YOU TO BILL WITH OR REVERSE THE PAYOR’S ACTION OR INACTION, YOU DON’T PAY A DIME.

*With contingency and retainer programs available, our primary goal is to ensure the faithful enforcement of all public health and safety laws that relate to timely reimbursement and prevent improper prospective, concurrent and retrospective denials. Our presence will help you instill preventive measures to encourage third party payors to adjust their practices and come into compliance with state and federal laws. (TRAF Early-Out members receive this service complimentary, without additional charge.)

Claims Representation

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.

VA Outsourcing

ERN/TRAF VA Outsourcing helps you ensure the government leaves no veteran behind.

We focus exclusively on providing regulatory claims representation along the revenue cycle designed to increase a hospital’s cash flow and VA regulatory compliance.

Client Focus:

We are exclusively focused on protecting patients and providers rights nationwide.
We dedicate a compliance team led by a senior-level executive to every provider member (client.)
We employ a consultative approach with clients to improve claims status and authorization requests from the VA for poststabilization services and care.
We offer multiple cash acceleration solutions from a single source.

Enforcement Campaigns – We provide a compliance environment for the VA to review and identify single and multiple violations to instill preventative measures and mitigate a provider’s loss.

Regulatory Complaint Filing – For VA Hospitals that do not self-initiate corrective action plans and redress violations, we escalate the issue to the appropriate VA Network Director for review and enforcement and will appear before the ALJ when requested.

Reporting – We provide transparent and timely reporting that identifies denial trends to track problem VA Hospitals and gain insights for optimized decision making.

Compliance – ERN/TRAF is compliant with each provider member’s policies and procedures. We are HIPAA compliant, and receive additional compliance training that governs uncompensated medical care annually.

The National Council of Reimbursement Advocacy (NCRA) advocates for uncompensated medical care, legislation and solutions on how to help providers fight for medically appropriate care (for their patients) in light of the significant burden on the nation’s emergency safety net. Visit us here to view our latest press releases and action against VA untimeliness of payment and mismanagement.

VIP Member Early Out Program

AT ERN/THE REIMBURSEMENT ADVOCACY FIRM (TRAF), WE EMPLOY A PROPRIETARY REGULATORY APPEALS PROCESS AND HAVE DEVELOPED AN INGENIOUS PROGRAM THAT IS SO SUCCESSFUL, YOU WILL FIRE YOUR COLLECTION AGENCY. WE GIVE YOU THE SECURITY & RESULTS YOU NEED TO INCREASE YOUR CASH FLOW AND HEAL YOUR PATIENTS.

The effects of age on uncompensated medical dollars can have a “devastating impact” on a provider’s ability to practice medicine. Experts will tell you that accounts drop in potential value the minute they go into default. And with each passing day, the accounts seem more difficult to recover.

Consider the following chart on account value in relation to age:

As you can see, at one month out, the value of an “owed” medical dollar drops to 94¢. At 6 months that patient account is likely to be worth only 58¢. And the chances of recovery of those claims without professional help are extremely slim.

Our job at ERN/TRAF is to maximize recovery of those claims for our provider members. Turning it over too late will make it cumbersome for our compliance auditors to get payment. In today’s economy, collection agencies have become ineffective and obsolete. ERN/TRAF is different. We provide prospective, concurrent, and retrospective reviews of denials. Our provider relations representative will be glad to meet with you to discuss how you can recover more from noncompliant payors with us.

For provider members that use our VIP “Early Out” Monthly Program, we offer the following benefits:

PRO BONO patient advocacy for disagreements of care and failure of plan to assume care for patient at your facility or arrange transfer to a contracted facility.
CCO online or chat support to help you resolve cases in-house (using laws that relate to timely reimbursement and prevent improper denials).
Quarterly supplemental or new hire training credits and certification of your staff (including annual updates) in our Professionals Claims Compliance Program (PCCP).
Discounts tuition on future NCRA PCCP Workshops.

All PCCP Workshops include:

THREE HOURS of in-class training for your employees, including FREE re-training at our Quarterly Claims Compliance Forums to increase their skills in claims compliances mastery each calendar year. This training will prepare your employees for NCRA Professional Certification (15 hours of training in ERN Certified Courses is required).
Dream team dispute writing workshops are conducted for at least half of topics covered. These interactive sessions provide appeal simulation and increase appeal success by concentrating on letter/script writing and verbal communication skills needed to overturn difficult denials.
Claims Compliance Certification Prep Testing available for an additional cost.