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Maintaining compliance with Medicare rules and regulations can be compared to marketing a small business: you could do it yourself, and you might have some success, but if you hire a professional, you’ll have more time, better results, and your savings will be significantly higher.

The hidden internal costs of DIY compliance

As a P&C insurance organization, your company employs dozens – perhaps hundreds – of claims adjusters who deal with a huge volume of claims over the course of a month. Only about 17% of those claims involve Medicare beneficiaries and only a portion of those claims fit the requirements for Section 111 reporting and repayment of conditional payments.

The adjuster position tends to have a somewhat high level of turnover, so you likely have an ongoing training program in place to get new adjusters up to speed and to keep veterans in the know as laws and best practices evolve. But with the average adjuster only seeing a handful of Medicare claims a month, how much time and money can you reasonably spend on training them to handle the often complex processes behind reporting and recovery? And how well can your training staff stay up-to-date on the constantly changing Medicare laws and regulations?

Truthfully, most companies that handle their own Medicare compliance leave themselves exposed to financial risk via inaccurate reporting, insufficient recovery payments, or consistent overpayment to Medicare because the claims adjusters are not aware of how to inspect a Medicare claim for invalid charges.

With penalties of $1000 per day per claim for failure to properly report, and double the damages plus interest for failure to properly reimburse a conditional payment, the added cost of training and overpayment is just the beginning.

So, in summary, the top three reasons DIY compliance is a bad idea are:

  1. Training employees (and training the trainers) requires a lot of time and money for a very small portion of the overall claim volume.

  2. Even with adequate training to identify and process Medicare claims, the desire to get the claim closed quickly often leads to overpayments which raise paid costs and reserves.

  3. Just the slightest mistake in following Medicare’s ever-changing procedures can result in delays in the compliance process and even disproportionately high fines and penalties, adding to the financial risk.

The best alternative available

Hiring a professional Medicare compliance service provider like Flagship, on the other hand, guarantees your company 100% compliance. We guarantee you’ll never pay us more than we save you while making your firm completely compliant.

In essence, we take on all the inherent risk involved in handling Medicare claims for you. We will:

  • Review your entire body of claims to ensure that every Medicare beneficiary is properly identified.

  • Report each claim using the proper software and techniques required by CMS.

  • Obtain the Conditional Payment letter outlining the bills Medicare has paid and determine whether they are related to the injuries sustained and dispute any unrelated charges.

  • Secure the final demand for repayment.

  • Obtain the case closure letter from CMS verifying the claim carries no further risk to you.

We are offering up a friendly challenge to you: take the time to review your current DIY compliance procedures and honestly determine what the total cost to your company is in terms of time and money. Then, contact Flagship and let us discuss how our services can mitigate risk and protect your financial resources.


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