A three-facility operator, twelve months of remittances, and the money that was hiding in them
A Bay Area senior care operator with three licensed RCFEs. Billing was done in-house on paper. Payments were arriving, so nothing seemed wrong. Here is what the remittance records showed, and what changed. Client identity withheld; every figure is traceable to payer remittance records.
Baseline, cleanup, stabilized
Historical baseline
Paper claims, no reconciliation. Remittances carried a median of about $9,000 in denied dollars each, and nobody was reading the denied section because the deposit matched the paid section.
Takeover and cleanup
Every remittance from the baseline period was reviewed and every denied or unbilled line was identified. Historical claims were rebilled in batches. Denied dollars temporarily rose during this period, which is what pushing a year of corrections back through adjudication looks like. It is evidence of cleanup, not regression.
Stabilized operations
Weekly runs, validation before submission, remittance review the week each payment posts. Remittances now cluster at the low-denial end while continuing to produce regular payment activity.
$424,306 of rebills became $205,818 of real exposure
The rebill batches overlapped. The same resident and the same dates appeared in more than one batch as corrections were resubmitted. Adding the batches together would have produced a recovery claim more than twice the truth.
So we de-duplicated first. The unique exposure, the dollars that were actually at risk, came to $205,818. Only then did we trace each dollar forward to a payment.
- $140,109 traced directly to later Medi-Cal payments, $138,590 paid in full and $1,519 on adjusted lines
- Within a single remittance of $247,633, rebilled lines accounted for $126,013, just over half the payment
- Confirmed ILS remittances bring the total to $179,854
The review pool is identified exposure not assumed recoverable. The appealed ILS balance is excluded from confirmed recovery.
Two people, one chain of custody
Electronic submission
Medi-Cal electronic claim certification passed, and Kaiser ILS clearinghouse testing completed. Claims leave with a receipt, and rejections are corrected the same day.
Validation before transmission
Every claim passes an automated check of eligibility, units, rates, and prior payments before it goes out. The errors that caused the baseline denials cannot be sent anymore.
Separate review
One person generates and sends. A dedicated remittance analyst reconciles and reports. Submission and review feed each other, and neither grades its own work.
What we did not count
- Confirmed recovered revenue includes only amounts tied to later payment evidence. Pending and denied items are excluded.
- The $65,709 review pool is reported as identified, not as recoverable.
- One source line with an inconsistent program label was retained exactly as supplied and flagged, rather than silently corrected.
- Period comparisons describe the supplied records. They are not presented as proof that every change was caused solely by the new process.
A line-level audit workbook tracing every recovered dollar to its remittance supports this case study and can be reviewed in sanitized form under NDA.
Your remittances have a story too.
The free review applies this same method to your last six months: de-duplicate, trace, and report only what holds up.