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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

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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