SEMINARS &
CONSULTING SERVICES
CLAIMS ADJUDICATION
Tired
of costly errors? Develop your claims scrubber
A claims
scrubber module represents the most basic cost containment tool for payers and
TPAs in adjudicating claims and for IPA and MSO analyzing claims paid by the
HMOs if risk agreements contracts are in place. Millions of dollars can be saved!
A claims
scrubber with pricing (fees) capabilities can simplify the job of case managers
estimating claims of services rendered by providers that are not participating
in the insurance company panel and are considered “out-of-network”
Our HPP AccuChecker
team has developed seven (7) claims scrubbers systems in the last fifteen years
– we learned that a team of programmers and healthcare reimbursement experts working
together can develop their own claims scrubber in 60 to 90 days. It is understood that adequate training and
a good map of the adjudication rules will guarantee the success of the in-house
scrubber.
A good
in-house claims scrubber must:
·
Adhere
to CMS and AMA adjudication guidelines in paying claims
·
Verify
members participation in the insurance plan
·
Validate
dates, places of service, procedures, modifiers, units, pricing, diagnosis
(ICD-9-CM and ICD-10-CM) codes and co-payments
·
Adjust
duplicate lines in claims
·
Keep
an eye on UPCODING and the relationship between E & M procedures and places
of service
·
Reject
double billing when global fees and modifier 26 are charged simultaneously for
the same day of service – common in hospital radiology services
·
Check
medical necessity by matching procedures and diagnoses
·
Identify
and react to UNBUNDLING by using up-to-date CCI tables
·
Track
payment of bilateral and multiple procedures including endoscopy services
·
Follow
basic rules on claims using numeric and alphanumeric modifiers for surgical,
medical, diagnostic and rehabilitative services
·
On
inpatient admissions observe that there is only one admitting physician and that
double charges for ER and admission are flagged
·
In
the case of Medicare and Medicaid HMOs stay in constant watch on the two major
areas of waste and mismanagement by some of the Plans – Pharmacy and Behavioral
Services
·
A
more advance analyzer will take care of HEDIS and PQRS measures – Alerting by
patients in file the measures required by member during the year and the status
of measures pending for each participant during the pertinent filing period.
FOR MORE
INFORMATION ABOUT
CLAIMS
ADJUDICATIONS
SEMINARS
& CONSULTING SERVICES
Please
contact us at (305) 227-2383
Email: sales@accuchecker.com
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