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

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 . .

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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

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Better cash flow!

Faster reimburse-ment

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

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Managed Care Boot Camp

Key Managed Care Points

• Medicare No-Pay Claims– HIC #– Condition Code

• Medicare/Medicaid Edits applied to Managed Care Plans

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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 HospiceSkilled Nursing Facility CarePart A/Part B Coverage

• Reporting Specific to Managed Care – Segmentation– Claims/Remittance/Denials (Get 835)

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Managed Care Boot CampKey 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

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Managed Care Boot CampKey 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

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