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Avoiding Healthcare Service Reimbursement Gaps

Lloyd R. Vaughan of Vaughan Holland Consulting, Inc., a solution provider company attending the marcus evans National Healthcare CFO Summit Fall 2012, on maximizing reimbursement in healthcare. 

Interview with: Lloyd R. Vaughan, Founder, Vaughan Holland Consulting, Inc.


Healthcare Chief Financial Officers (CFOs) cannot do much about the reimbursement rates that Medicare has set, but they can make sure their organization is paid for all services provided, says Lloyd R. Vaughan, Founder, Vaughan Holland Consulting, Inc.

From a solution provider company at the upcoming marcus evans National Healthcare CFO Summit Fall 2012, in Dallas, Texas, October 21-23, Vaughan discusses how to maximize reimbursement for healthcare services through better billing practices.

How has the reimbursement environment changed in recent months?

Recovery Audit Contractors (RACs) are placing a lot more emphasis on finding overbilling and taking money back from hospitals, causing a lot of consternation and demanding a lot of time from hospital folks to come up with the requested records and to challenge take backs. This is definitely a strong trend that has picked up in the last year.

Medicare intermediaries that process bills are also becoming more difficult to work with. We help hospitals submit corrected bills and are constantly facing road blocks, of intermediaries making us submit paper documents that pretty much disappeared 15 or 20 years ago.

How could hospitals avoid reimbursement errors from the start?

Healthcare CFOs need to be more vigilant with what types of patients are admitted as inpatients. RACs are challenging many inpatient claims, saying that they could have been done on an outpatient basis. There are specific guidelines to determine who should be admitted as an inpatient, with some level of judgment involved, but it takes experienced case managers to guide patients to the right setting. If this is done right on the front end, it would help hospitals avoid disputes with Medicare.

Secondly, when RACs take money back, hospitals are allowed to appeal. Some hospitals are challenging every single case, while others are not. I think they should challenge all of them aggressively and put RACs on notice, so if they do submit adjustments, they make sure to be right about them.

Should certain services or types of patients be prioritized to maximize reimbursement? How can they avoid services falling through the reimbursement gap?

First, they need to know what their services cost and have a good cost accounting system. In order to know what to charge and how much reimbursement to pursue, they must know what the services cost and how much Medicare and other payers actually pay for them. In some cases, reimbursement may be too little compared to the time and effort that would need to go into it. Hospitals may need to re-evaluate some of their services. Outsourcing certain services or collaborating with other organizations might be better.

It is hard for any hospital, no matter how big or sophisticated, to provide every service in a way that is cost effective, so CFOs have to be more open minded about the alternatives.

Any final thoughts?

CFOs cannot do much about the rates that Medicare has set, but they can make sure their organization is paid for all services provided. That requires someone to come in and take a look at the claims, and make sure they are paid for everything.

Contact: Sarin Kouyoumdjian-Gurunlian, Press Manager, marcus evans, Summits Division

Tel: + 357 22 849 313

About the National Healthcare CFO Summit Fall 2012

This unique forum will take place at The Westin Stonebriar, Dallas, Texas, October 21-23, 2012. Offering much more than any conference, exhibition or trade show, this exclusive meeting will bring together esteemed industry thought leaders and solution providers to a highly focused and interactive networking event. The Summit includes presentations on increasing efficiency in an era of accountable care, growth strategies for today’s market, healthcare reforms and reinvigorating revenue cycle performance.

For more information please send an email to or visit the event website at
marcus evans group – healthcare sector portal

About Vaughan Holland Consulting, Inc.

Vaughan Holland Consulting, Inc. specializes in recovering lost revenue for hospitals.  Since 1996 the company has done specialty audits of Medicare, Medicaid and contracted payers.  The company has approximately 200 hospital clients.

About marcus evans Summits

marcus evans Summits are high level business forums for the world’s leading decision-makers to meet, learn and discuss strategies and solutions. Held at exclusive locations around the world, these events provide attendees with a unique opportunity to individually tailor their schedules of keynote presentations, think tanks, seminars and one-on-one business meetings. For more information, please visit 



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