We specialize in improving and protecting hospitals’ net revenue so they have the resources to provide better care to the community.
MedCom Solutions operates its business and delivers its core services on a foundation of ethical and appropriate professional conduct. MedCom staff follow employment code of conduct guidelines and are well educated on the Annual MedCom Corporate Compliance Program including but not limited to privacy and security standards, business ethics, confidentiality, conflict of interest, business associate agreements, channels of communication, customer relations, compliance reporting and audit mechanisms, and designated leadership roles.
Passionate people with exceptional experience
Founded as MedSoft Systems & developed pricing software: Strategic Hospital Pricing (SHP).
Hamot Medical, a 500-bed hospital located in Erie PA, became MedSoft’s first client to license SHP software.
MedCom licensed SHP software to a national hospital management firm Quorum Healthcare.
MedCom developed an adjacent software product, Comprehensive Budget System (CBS), that imports current financial data used to forecast volume, pricing, expenses, and reimbursement for the next fiscal year. Included is the HCFA 2552 Cost Report stepdown workpaper that calculates Medicare reimbursement.
Medsoft Systems assigned its assets to MedCom Solutions due to common usage of MedSoft for many new entrepreneurial firms that are developing throughout the United States.
MedCom Solutions was incorporated on October 2, 1989.
First firm in the US to create software that captures the necessary data for a new reimbursement methodology: Minimum Data Set (MDS).
The complex nature of the healthcare industry and regulatory agencies have substantial influence on the chargemaster.
MedCom began to provide consulting services for chargemaster management review for CPT codes, revenue codes and general ledger mapping.
MedCom was approached by a large hospital to assist with a Department of Justice (DOJ) fraud investigation.
Negotiations between the hospital and the DOJ were predicated on Medicare’s 72 Hour Rule. MedCom developed a Medicare compliance software product that reads Medicare’s 835 Remittance Advice to determine if any outpatients were paid within the 3-day rule.
OIG-72 Compliance Audit Software was designed to take advantage of the immunity provision included in Section 8(b) of the DOJ settlement package. This was developed to protect the hospital from further fines and penalties.
Allegheny General Hospital approached MedCom to develop a Medicare payment audit software product that measures actual cash amounts received by fiscal year and by HCFA-2552 Cost Report reimbursement classification. The 835 Remittance Auditor software was used to reconcile every daily 835 payment file to the penny of the actual cash deposit to the hospitals bank account.
Most importantly, the Remittance Auditor uncovered episodes where Medicare had double counted the cash received. Consequently, reconciliation of each fiscal year cost report for the hospital was accurately accounted for on the “To/From” final accounting.
MedCom provided a total pricing review for a large academic medical center. MedCom used Strategic Hospital Pricing to conduct the review revealing a $200 million net revenue improvement.
MedCom began to audit IT system integration of order entry connectivity to chargemaster charges. MedCom uncovered that 21 order entry systems at a large academic medical center had charge capture failures.
After one year of manually auditing and correcting the charging issues, the hospital pickup exceeded $250 million in net revenues.
An example occurred where the professional anesthesiology reimbursement was shorted over $30 million due to a yes/no toggle set to “no”. Its setting would not allow for more than one volume to be processed for each of the 15-minute billing increments, regardless of the actual volume of time increments.
An Urban Academic Medical Center, with professional and technical chargemasters each exceeding 75,000 lines, petitioned MedCom to develop a software product to control and approve all chargemaster requests vis-à-vis its Pittsburgh headquarters.
MedCom developed a base Chargemaster Management Navigator (CMN) and controlled the client’s chargemasters for the next 5 years with continuous improvement and accuracy of patient claims.
Over the course of five years the contractual allowances decreased from 62% to 48% while gross revenue increase by $2.0 billion.
MedCom was asked to work with Cleveland Clinic’s joint venture for a hospital being constructed in Saudi Arabia. The International Medical Center needed to have the chargemaster built from the ground up. MedCom went onsite and developed the chargemaster in two months.
A Pittsburgh urban teaching hospital was incurring patient claim denials for lack of medical necessity. MedCom developed a software product, ABN Crosswalk. It was designed to be used by the registration staff that reads in the ICD-9/ICD-10 diagnosis code and crosswalks it to the CPT/HCPCS codes to determine if the diagnosis supports the services about to be performed. If the procedure is not supported by the diagnosis, the patient is asked to sign an Advanced Beneficiary Notice, (ABN).
Alternatively, when ABN Crosswalk alerted the registration staff of a medical necessity problem, the staff would call the physicians office to determine if the initial diagnosis codes were incorrect. If it was determined that they were, an alternative code would be provided.
Within three months, medical necessity claim denials were reduced by over 80%.
MedCom developed a means of classifying medical procedures by clinical families that identify resource value of one procedure to the other.
The Groups & Ranks file was used to manage chargemaster pricing to appropriately scale charges in order of resource value for appropriately tiered pricing.
A large national healthcare system requested assistance with merging a newly purchased hospital’s chargemaster to the corporate standard chargemaster.
MedCom successfully utilized its C3 Software to accurately merge the acquired hospital system into the corporate standard chargemaster.
A large national healthcare system requested that MedCom align the Operating Room Surgical time charges on a national basis. It was to be congruent regardless of the hospital where a patient is seen. Surgery time charges are found to be both inconsistent and correspondingly suffer from underpayments.
MedCom developed a process that provided uniform charge alignment for all 60 hospitals. It was reported that an average increase to net revenue exceeded $1,000,000 per hospital.
Using the 835 Medicare payment file from all payors, MedCom developed a reporting product called RANavigator™ to identify where payment failures occur.
This reporting package was developed to classify denials for C-Suite reporting. Most importantly, RA Navigator provides the C Suite with a “birds-eye” view of the progress to reduce the volume of denials as an independent, clear view for non-PFS executives.
Developed a new workflow utilizing CMNavigator that gives material management staff the ability to concurrently input new items into the material management system and the chargemaster providing a true link between the Item Master and the Chargemaster.
MedCom discovered, while working with a large New York hospital system, that it was incorrectly charging surgical services. It was found that 85% of all surgery was classified as level 2 of 6 different levels, causing revenue shortfalls for higher acuity surgical cases.
In response, MedCom invented a means of distributing surgical cases on an acuity measurement over the six surgery levels that is more accurate for services provided. After actual implementation, the hospital generated over $5,000,000 of additional net revenue.
Medicare issued proclamations that force hospitals, physicians, and insurers to disclose patient pricing. Regulations require certain prices to be deemed “shoppable” and all pricing to be made available vis-à-vis websites.
MedCom piloted its approach with a small rural hospital to develop the compliant protocol that meets both the publication of prices and the digital compliance on its website.
Knowing the economic value of a surgeon can be a daunting task for a small hospital. Measuring the professional value of a physician and the technical value of the services brought into the hospital by a surgeon are imperative to determining the surgeons value. Windber Medical Center was lacking in both means of measurement.
After meeting with the professional and hospital surgical staff, MedCom developed an analytical tool that incorporates multiple IT system databases in conjunction with the professional and technical 835 remittance advices.
The Surgical Advisor provided the economic picture of each surgeon, illustrating the gross and net revenue factors in comparison to the cost factors to produce a bottom-line score card for both employed and non-employed surgeons.
"Hospitals are better at collecting data than analyzing it. MedCom has proven their value in their ability to analyze intrinsic surgery data to provide a strategy for restructuring the operating room theater to gain total reimbursement."
Alice Pope, Chief Financial Officer, HonorHealth
"I have worked with MedCom Solutions on several occasions, and have found their work to be excellent. Their consultants are knowledgeable and thorough. They are also good listeners who pay attention to the client's needs, and then pay attention to all the details."
Jerry Feddersen, CEO Tulane University Medical Group
