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Millions in Underpayments from HMO's

Oct 08, 2007

MIAMI, FL -- Most physicians' offices deposit checks received from HMOs and other payers with no questions asked, without verifying fee schedules or analyzing how the claim was adjudicated. Millions in underpayments remain undetected.

- Generally HMOs UNDERPAY claims coded with modifiers (see definition below)
- HMOs' Adjudication System cannot correctly adjudicate complex coding
- Medicare HMOs found in violation of Medicare Guidelines
- HMOs appeal process is tedious and cumbersome

A modifier is a code appended to claims to denote that the service rendered was altered.
- Many times the use of modifiers impact the reimbursement amount paid.
- Modifiers ensure the correct payment for services.
- Thousands of daily claims issued are coded with modifiers.

During the last two years, www.Accuchecker.Com, LLC has been chasing underpayments from HMOs. Many forms of underpayments were detected - from shaving off repetitive small amounts that will add to millions of dollars for the HMO plan - to the most horrific discovery: HMOs Adjudication Systems fail to properly pay physicians correctly, specially claims including modifiers such as bilateral procedures and multiple surgeries just to name a few.

The overly priced HMOs' Adjudication Systems fail to accomplish their mission because software developers put emphasis in improving members' services, tracking outcomes and in generating excellent administrative reporting ignoring how to properly adjudicate claims with complex coding. In addition HMOS fail to adequately train its people to correctly process and recognize modifiers and other coding.

WWW.ACCUCHECKER.COM, LLC has concentrated its effort in the recovery of undetected UNDERPAYMENTS from Medicare HMOs and is rapidly becoming a leader in the industry recovering underpayments which are a clear violation of Medicare Guidelines. Medicare HMOs must adjudicate claims following Medicare guidelines.

CMS and the Office of the Inspector General are more interested in policing Medicare providers for fraud and abuse than in supervising Medicare HMOs' underpayments.

How difficult is for healthcare providers to recover from underpayments and denials?

A contractual agreement between HMOs and physicians precludes HMOs' participating providers from the regular appeal process that physicians enjoy when dealing with Medicare.

- Under the Medicare system, providers have multiple levels of appeals and if you can provide adequate documentation to substantiate your claim, Medicare usually pays.
- It is quite different when physicians appeal denials from HMOs.
- The HMOs plans have the upper hand.
- Chances of recovering denials from HMOs are extremely difficult.

If your practice bills HMOs claims coded with modifiers, chances are that you are receiving underpayments.

We at ACCUCHECKER.COM, LLC have successfully developed a plan to assist physicians in recovering underpayments from HMOs. Reports outline underpayments and violations of basic guidelines.

We would like the opportunity to send you sample reports of HMOs' underpayments Recovery. Please contact to obtain your FREE sample report.

By Pablo Silverio
Managing Partner of WWW.ACCUCHECKER.COM, LLC


WWW.ACCUCHECKER.COM, LLC is a consulting firm based in Miami, FL they are the developers of the AccuChecker Product Line. The company is devoted share reimbursement solutions to the healthcare industry. receives more than one million pages viewed every month.

The AccuChecker Product Line consists of 4 basic products:

- AccuChecker OnLine -an Internet subscription database with procedures, diagnoses, Medicare fee schedules and coding techniques like Corrective Coding Initiative (CCI), medical necessity and how to code modifiers.
- Expertise and knowledge of how to create private label scrubbers for practice management systems and for small payers
- Reports and practical methods to recover UNDERPAYMENTS for HMOs
- Reports to analyze the Medicare business of a practice.

FREE services to the healthcare community like UPIN and NPI search or NPI number

Pablo Silverio, Managing Partner of WWW.ACCUCHECKER.COM, LLC

A healthcare consultant assisting physicians and managed care organizations since 1983

Pablo Silverio has been active in multiple areas of healthcare:

- Has represented physicians in more than 500 Medicare and Medicaid audits since 1986

- Developed the AccuChecker Product Line. Today the company has hundreds of clients across the nation like physician offices, billing services and managed care plans accessing our online service searching for reimbursement information or sharing our expertise in developing private label scrubbers

- Has conducted coding and claims adjudication seminars across the nation

- Developed a new concept in reimbursement a recovery system capable of detecting OVERPAYMENTS and UNDERPAYMENTS from claims paid by managed care organizations and other insurance carriers.

Education: Business Administration University of Tampa

Developers of the AccuChecker Product Line
9460 Fontainebleau Blvd Suite 523 Miami, FL 33172
Phone: (305) 227-2383
Cellular: (786) 231-7585

Pablo Silverio
Phone: (305) 227-2383
Cellular: (786) 231-7585

Keywords: underpayments, Medicare HMOs, HMOs, managed care  Government » Healthcare

Contact Info
  • Accuchecker, LLC
  • Pablo Silverio
  • 786-231-7585