Utilizing managed care claims data effectively for improved revenue
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Utilizing Managed Care Claims Data Effectively for Improved Revenue PowerPoint PPT Presentation


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Managed Care Boot Camp. Utilizing Managed Care Claims Data Effectively for Improved Revenue. Presented By: Kerry Elledge Quadax, Executive EDI 5/16/2013. Managed Care Boot Camp. Revenue cycle systems & services Exclusively serving the Healthcare market

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Utilizing Managed Care Claims Data Effectively for Improved Revenue

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Utilizing managed care claims data effectively for improved revenue

Managed Care Boot Camp

Utilizing Managed Care Claims Data Effectively for Improved Revenue

Presented By:

Kerry Elledge

Quadax, Executive EDI

5/16/2013


Managed care boot camp

Managed Care Boot Camp

  • Revenue cycle systems & services

  • Exclusively serving the Healthcare market

  • Privately held company, 550+ employees

  • 800+ clients in over 33 states

    ~ 766 EDI Services clients (7 States)

    ~ 50 A/R Services clients

  • Client retention of 95%+ has been driven through true partnerships

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Managed care boot camp1

Managed Care Boot Camp

  • Claim Drop – From Host System

  • Scrub-A-Dub Dub:

    • Edits: Payer, NCD, LDC, CCI, MUE, OCE

    • Edits: Custom

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Managed care boot camp2

Managed Care Boot Camp

  • Auto Release (Clean) or Correct and Release

  • Off to the Payer – Accept or Reject

  • Into the Payers Adjudication System – To Pay or Not to Pay…That is the ?

  • Return 835/Remittance

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Managed care boot camp3

Managed Care Boot Camp

  • Medicare No-Pay Claims

    • HIC #

    • Condition Code

  • Medicare/Medicaid Edits applied to Managed Care Plans

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Managed care boot camp4

Managed Care Boot Camp

  • Eligibility Edits – Medicare

    • Check various eligibility information

      • HMO Managed Care/PPO (Includes Plan ID and Name)

      • Enrolled in Hospice

      • Skilled Nursing Facility Care

      • Part A/Part B Coverage

  • Reporting Specific to Managed Care – Segmentation

    • Claims/Remittance/Denials (Get 835)

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Managed care boot camp5

Managed Care Boot Camp

  • Claims are processed more quickly - You receive payment faster

  • You’ll be aware of denials sooner with greater opportunity to reverse

  • Key savings opportunities

    • No longer paying postage

    • No longer have to pay for the forms

    • Save employee time of manually creating secondaries

    • Streamlined follow-up

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Managed care boot camp6

Managed Care Boot Camp

  • Effective denial management strategy

    • Identify, Classify, Quantify

    • Manage Denial Follow-Up

    • Prevent Denials Through Process Improvement

    • Develop Effective Reporting

Where do denials come from?

Any and all points in the revenue cycle

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