Utilizing Managed Care Claims Data Effectively for Improved Revenue

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

2. 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 . . . . .. ..

3. Managed Care Boot Camp • Claim Drop – From Host System • Scrub-A-Dub Dub: • Edits: Payer, NCD, LDC, CCI, MUE, OCE • Edits: Custom . . . . .. ..

4. 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 . . . . .. ..

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

6. 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) . . . . .. ..

7. 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 . . . . .. ..

8. 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 .. .. ..