Utilizing Managed Care Claims Data Effectively for Improved Revenue Presented By: Kerry Elledge Quadax, Executive EDI 5/16/2013 Managed Care Boot Camp.

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Presentation transcript:

Utilizing Managed Care Claims Data Effectively for Improved Revenue Presented By: Kerry Elledge Quadax, Executive EDI 5/16/2013 Managed Care Boot Camp

Introduction: Quadax 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....

Managed Care Boot Camp Claim Life Cycle - EDI Claim Drop – From Host System Scrub-A-Dub Dub: –Edits: Payer, NCD, LDC, CCI, MUE, OCE –Edits: Custom.... Better cash flow! Faster reimbursement Cleaner claims

Managed Care Boot Camp Claim Life Cycle - EDI 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....

Managed Care Boot Camp Key Managed Care Points Medicare No-Pay Claims –HIC # –Condition Code Medicare/Medicaid Edits applied to Managed Care Plans....

Managed Care Boot Camp Key Managed Care Points 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)....

Managed Care Boot Camp Key Managed Care Points: Automated Secondaries 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....

Managed Care Boot Camp Key Managed Care Points: Denial Management Effective denial management strategy –Identify, Classify, Quantify –Manage Denial Follow-Up –Prevent Denials Through Process Improvement –Develop Effective Reporting Scheduling Service Providing Service Coding Service Billing Service Collecting Payment Where do denials come from? Any and all points in the revenue cycle......