Business Process Engineering (BPE) Insurance Claims Clearinghouse

Home Case Studies Business Process Engineering (BPE) Insurance Claims Clearinghouse

Solution Overview

Industry
Healthcare
Workmans’ Liability Claims
Processing

Development Time
4 months

Benefits
This claims processing clearinghouse is now ready to provide an automated-EDI-driven service to efficiently and quickly process cllaimfs between the provider and payer.
Customer satisfaction is expected to rise as a result of a more supportive and more clearly-focused work environment, resulting in lower cost per claim and faster. settlement of claims.

Technology
Microsoft .Net and SQL Server database
CHALLENGE

A medical claims clearinghouse like QFMC plans to bring tremendous efficiencies to the processing workmans’ compensation claims worked on by its several Physical Therapy (PT) clinics throughout the Central States.

Next Generation Technology is helping this clearinghouse Transmit Electronic Claims to Insurance Carriers through EDI (Electronic Data Interchange. Along the way, the software that we are developing will store information about the claims in a relational database for ongoing analysis and metrics review on the volume and nature of the claims processed. This business intelligence will help future efforts to improve the claims processing thus reducing the cost-per-claim.

Imagine several hundred licensed healthcare providers all using a different claim software, sending out medical claims to over 100 different insurance payers, daily - across several different states - each state having its own insurance regulations; and then each carrier having its own internal software infrastructure.

In essence, what you have is the perfect recipe for an information super disaster.

In essence, what you have is the perfect recipe for an information super disaster.

SOLUTION

To bring efficiencies to this claims-processing labor-intensive workflow, Next Generation Technology is working with QFMC to develop software to handle the processes electronically.

Enter the processing of healthcare claims transmitted electronically. Sounds great you say, except that you no longer have a US Postal Service to do the transmitting. Electronic claims clearinghouses will ‘connect’ the provider (in this case, PT clinics) and the payer of the claims electronically where the postal service was unable to do efficiently and rapidly.

Most simply, clearinghouses like QFMS are aggregators (senders and receivers) of mountains of electronic claim information almost all of which is managed by software developed by Next Generation Technology .

The medical billing software creates the electronic file (the claim) also known as the ANSI-X12 837 file, which is then uploaded to a clearinghouse account. The clearinghouse then checks the claim for errors and then the electronic claim is securely transmits to the payer with which it has already established a secure connection that meets the strict standards laid down by a HIPAA.

A status message is sent back to the clearinghouse who then updates that claim's status in your claim software. It then alert's you with a status update that you have a processed claim. Ultimately, the provider receives a reimbursement check along with an explanation of benefits (EOB).

The same sort of activity takes place every night within the federal banking system as our checks and banking activities are sent electronically from local banks to central ACH repositories

BENEFITS

The QFMC clearinghouse will offer high value features that provide a whole new level of claim intelligence for revenue cycle management that makes their services extremely compelling from a financial perspective.

Here are some highlights to look for in a premium claims clearinghouse:
  • Eligibility Verification - Determine coverage before treatment
  • Electronic Remittance (ERA) - Automatically updates patient accounting
  • Claim Status Reports - Know the status of a claim at all times
  • Rejection Analysis - Have error codes displayed in plain English
  • Online Access - Edit and correct claims day or night online
  • Printed Claims - When necessary have medical claims automatically dropped to paper but still be able to track them electronically.
  • Affordability - When you take into consideration the cost of purchasing forms printing envelopes and postage; a clearinghouse is cost-efficient.

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