Healthcare providers dealing with MassHealth patients turn to PV Kent & Associates to circumvent the traps and pitfalls of processing claims with the Office of Medicaid. We understand the unique intricacies of dealing with MassHealth. In addition, we have established excellent working relationships with the Office of Medicaid that often allow us to expedite payment.

Kent applies its Best Practices for Reimbursement to managing claims submissions to MassHealth. Our procedures maximize the accuracy and completeness of every claim and ensure adherence to every step of the claims process.

Kent's MassHealth Claims Services
Because we are intimately familiar with MassHealth regulations and procedures, we are ideally prepared to:

• Handle issues specific to inpatient and outpatient services
• Investigate and resolve issues that arise out of Medicaid Eligibility

   Verification System restrictions
• Pursue payment and coordinate split payments between MassHealth and its

   managed care organizations, including Neighborhood Health Plan, Network

   Health, BMC HealthNet, and Fallon Community Health Plan
• Resolve issues surrounding dual diagnosis claims (e.g., medical vs.

   psychiatric/substance abuse)
• Pursue retroactive and prior authorizations
• Retrieve and provide medical records to the Office of Medicaid, as necessary

   and appropriate
• Ensure consistency and accuracy of universal billing and claims correction

   forms
• Ensure consistency and accuracy of diagnosis and procedure codes
• Resolve issues with primary care physician/clinician referrals
• File appeals with the FDAB (Final Deadline Appeal Board)
• Challenge medical necessity claim denials
• Request fair hearings
• Perform legal reviews and file CJRs (Complaints for Judicial Review) as

   authorized by our clients

Claims Submission
When it comes to MassHealth claims, the bottom line is, "A Clean Claim Gets Paid." Our claims processing team scrutinizes submissions for likely errors, inconsistencies, and missing data.

We work with our clients’ various departments to ensure the accuracy of authorizations, referrals, coding, medical records, hospital clinical notes, proof of facsimile submissions, and much more. In the event that a claim involves motor vehicle insurance, workers’ compensation, the Veterans Administration, or other insurers, we coordinate benefits and the hierarchy of payment, as necessary.

We submit most claims electronically; we can also send facsimile or hardcopy claims, as the circumstances warrant.

Claims Tracking and Reporting
Kent’s fully automated collection/tracking/scheduling system allows our specialists to expedite the reimbursement process. It also permits our clients to ascertain the status of every claim in real time.

Our automated system generates customized reports that offer extraordinary insight into general trends, granular details, and provides tactical and statistical information for use in improving processes and procedures. Since information requirements vary greatly among healthcare providers, we tailor our reports to each client's specific needs.

In fact, Kent managers review the same reports for quality control purposes. They look for repeated problems, recommend remedies, and provide in-service training, showing clients how to avoid these problems by changing the way they work. We provide these services at no extra cost as part of our ongoing partnership with our clients.

Denials and Appeals Management
Healthcare providers miss out on hundreds and thousands of dollars of potential revenue each year due to incorrect denials from MassHealth. These losses often occur because of inadequate staffing, delays, and mistakes that are simply beyond the healthcare providers' control.

Kent prevents and appeals denials with a level of attention that would be impractical for most healthcare providers. Even before a claim is submitted, our MassHealth specialists discover and rectify potential problems caused by incomplete or inaccurate forms, billing deadline discrepancies, coding errors, and lack of referrals.

In the event that MassHealth denies payment, we notify our client of the result and the reason. If the denial is unjustified, our appeals specialists resubmit the claim with the corrected and amended information.

Legal Follow-Through
In the instances where standard appeals procedures are unsuccessful and/or the Office of Medicaid denies a claim for improper administrative reasons, Kent’s legal team offers advocacy and negotiation services, as well as litigation support. Our attorneys have the qualifications to appeal claims to the highest level, request fair hearings, and file complaints for judicial review with the appropriate court, when necessary and appropriate. These capabilities make us unique in the industry and often eliminates the need for multiple outsourcing efforts.