Kokua Medical Ventures (KMV) mission is to provide healthcare solutions that help in providing quality patient care coordination through specialized efficient services that can improve patient care, improve revenues and reduce wasteful, inefficient and ineffective practices that commonly affect all stakeholders in the healthcare system today.

Current Problems:

Throughout a patient’s continuum of care, plan sponsors, employers and patients are often frustrated with the processes included to diagnose an issue, create a treatment care plan that meets the patient’s needs, and implement services while keeping healthcare costs affordable. This is largely due to three factors:

  1. Insurance and industry changes that happen yearly, quarterly, and in some cases monthly and providers can NOT keep up with these changes.

  2. Inefficient supply chain management lead to concerns about reimbursements.

  3. Providers face unknowns in whether a claim will be paid or not due to hardships in getting claims approved, documented which ultimately decreases revenue for the practice.

Insurance Challenges With Administration:

ERISA guidelines govern how plans are funded and how funds tied to those policies are supposed to be administered. Since the Affordable Care Act (ACA), insurance payors have implemented policies that place the financial burden on the treating provider and/or patient to implement care services. The policies are designed to partially pay, deny, or delay approvals. This causes undue stress on all parties in the healthcare system. This includes the provider of services, plan sponsor and most importantly the patients. These policies are designed to increase insurance payor profits.

Why Claims Are Denied:

In an audit on insurance payors, the California Nurses Association found that the top seven health plans in the state of California:

  1. Denied 26% of all submitted claims or 13.1 million claims during the first three quarters of the year.

  2. The top payors to deny claims were Cigna at 39.6% and Blue Cross at 27.3%. This is mostly due to AI companies owned by payors that allow them to deny claims in hundreds of batches within minutes of receiving the claim. Look up Carelon and Evicore!

  3. According to the report, practitioners were only receiving 83.93% of their in-network contracted rate.

 The most commonly used reasons for insurance payors issuing denials or partial payments, include:

  1. Usual and Customary Rates used to pay a claim were lower than the summary plan document and/or contract fee schedule

  2. Establishing medical necessity and not utilizing the specific ICD-10 coding options available at that given time

  3. Deeming a product experimental or investigational

  4. Documenting medical necessity during examinations with limited SOAP notes

  5. Requiring Prior Authorizations, knowing that it will require on average 21 – 45 minutes of staffing time to obtain approval

  6. Saying that a product is deemed as an excluded service or service that they do not cover based on coding provided

  7. Other factors included timely filing requirements, deeming that the payor did not receive the claim although it was submitted, as an example, in Cigna corporate policy, they were found to have a process to delete every third claim

  8. Exceeding the maximum allowable benefits of a patient, or not following procedures according to the insurance payor internal policies

It’s important to note that these are just a few of the common tactics that have been incorporated by payors. All of these policies are designed to off load costs to patients, practitioners, healthcare facilities, and vendors, which in-turn, increases profitability to insurance payors.

The most common reason for denials or prior authorization requests include:

  1. Poor documentation in the clinical SOAP notes

  2. The treating provider is unable to negotiate the claim with the payor, offloading the approval process to uninformed patients.

  3. No real-time access to product/service recognition that identifies what is covered under the patient’s specific plan, this is largely a reason why 5 patients may be treated in a day under the same insurance carrier but some might be paid, underpaid, require a prior auth and/or be denied

  4. Inefficient billing strategies that prohibit a claim from being worked to its fullest (such as: Should the practitioner of service pay someone $15 an hour to work a claim over the phone with the payor that may take 45 minutes with no assurance of a positive outcome).

The Solution: 

Kokua Medical Ventures provides a centralized platform and team of experts that integrates all parties within its platform (practitioners, patients, manufacturers, and wholesale partners) throughout the entire patient continuum of care to counteract these inefficiencies.   

From patient registration to patient release - the patients, practitioners, and suppliers all work together in one ecosystem that allows Kokua Medical Ventures to offer patients a customized approach to care. This ensures medical necessity and proper documentation is met without any uncertainty.