Medical Claims Compliance

Medical Claims Compliance™ Comprehensive Analysis of Medical Transactions Data Harmony Users Group John Kuranz CEO Access Integrity, Inc. February 8th, 2012

Medical Claims Compliance™ Comprehensive Analysis of Medical Transactions Problem Process Product

ProblemRejection, Denial, Audit & Fraud

 Claims denial, rejection, audits and recovery processes are common to managed healthcare organizations Non-compliant medical transactions undermine a providers ability to focus on providing high quality healthcare services to their patients due to: • Increased risk of compliance audits • Rejection rates of 30% increases costs of claims rework & resubmission • Coder inefficiencies burdens profitability of provider business • Reduced cash flow $350 billion in overpayments in healthcare annually – i.e. upcoding, unbundled payments, fee calculation errors, adjudication errors, missed discounts, LCD/NCD miscoding, etc. $226 billion is annually lost to healthcare fraud

ProcessComprehensive Analysis of Medical Transactions

Physicians, Group Practices Hospitals, Clinics PA’s, NP’s & RN’s Nursing Homes Services Providers $$$ 1,200 Payers300 Million Patients 700,000 Providers1+ Billion Patients Records 53+ Million Procedures 4+ Billion Claims

ProductApply an existing technology to a new application

Medical Claims ComplianceUser uploads single or report shows coding andbatch of claims for billing error.verification Access Integrity AI2 Server Business Logic (M.A.I.) Validate form and note information

AI2 Claims Processing837 DataForm 1500 AI2 Reports Error TypesElectronic HealthRecords Error messagesPhysicians NotesEtc. ETL and Enrich with Metadata Extractor XML Repository Machine Aided Export data Indexer (M.A.I.™) XML CPT CSV HCPCSICD 9 Codes Business Logic LCD/NCD Verification DTD Driven NCCI LCD/NCD RVU Sequences Policies Medically Unlikely Edit RVU NCCI Age/Gender Specifics Codes Global Fee Periods MUE Physicians Fee Charges Message

Medical Claims Compliance Health Information Network

Product Features• Search all three code sets simultaneously (CPT, HCPCS & ICD) and apply correct modifiers• Analyze information found within physician narratives (EHR & Procedure Notes)• LCD/NCD verification (local and national coverage determination)• Physician fee calculator• Compliance with NCCI policies• Process ANSI 837 EDI and other common claim file formats (about 4 in total)• (MUE) Medically Unlikely Edits• Age and gender-specific procedures• Accurate global fee periods• Correct RVU (Relative Value Units) sequencing• LMRP (Local Medical Review Policies) medical necessity check• Form 1500 CMS data element evaluation• Web-based, standalone, HIPAA compliant• Download reports to spreadsheet

Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help

Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin HelpINDICATIONS FOR SURGERY:The patient is a 10-year-old white female child with a history of chronic tonsillitis refractory to medical therapy. She wastaken to the operating room for adenotonsillectomy. Witnessed informed consent was obtained prior to the procedure.PREOPERATIVE DIAGNOSIS:Chronic tonsillitis.POSTOPERATIVE DIAGNOSIS:Chronic tonsillitis.ANESTHESIA: Suggested ICD-9 and CPTGeneral endotracheal anesthesia.SPECIMEN: codes resulting from aTonsils and adenoids.FLUIDS: Crystalloid. review of physician andCOMPLICATIONS: None. procedure notesESTIMATED BLOOD LOSS: Less than 20 cc.FINDINGS: Large cryptic tonsils and moderate adenoids. Palate normal.DESCRIPTION: The patient was brought to the operating room and general anesthesia was established via endotrachealtube. Intravenous ampicillin and Decadron were administered. She was placed in the rose position. A Crowe-Davis mouthgag was inserted. The adenoids were removed with the adenoid curet. The nasopharynx was packed. The tonsils wereremoved using electrocautery to dissect between the superior constrictor muscle and the tonsillar capsule. Hemostasis ICD9 codewas achieved with suction cautery. With adequate hemostasis, the pharynx was irrigated and suctioned free of CPT codesecretions. The stomach was emptied free of secretions. She was awakened from anesthesia without difficulty.

Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin HelpThis is a 70-year-old female who has a history of symptomatic ventral hernia. She was advised to undergo laparoscopicevaluation and repair. The risks and benefits including bleeding, infection and cardiopulmonary complications werediscussed with her and she was anxious to proceed.Under a general anesthesia, an incision was made in the epigastrium and dissection was carried down through thesubcutaneous tissue. The abdomen was insufflated with C02. Two 5 mm trocars were placed, one in the left upperquadrant and one in the left lower quadrant. We were able then to circumferentially dissect the area of the hernia, which Mary Nelson 18 Mulberry Drive, Skokie IL 60010 312-345-6736 03 15 2011 02 16 2011 8502 90472

Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help

Complete AnalysisMedical Claims Compliance checks each submission and producesdetailed reports in seven specific areas: • Code set and modifier validation • Physician narrative compared against claim form • NCCI verification • Correct fee capture • LCD/NCD compliant usage • Medically Unlikely Edits (MUE) checked • Form 1500 data element compliance • Correct RVU • Global period eligibility

Provider Benefits• Reduces risk of compliance audits• Expedites claims submission and allows real-time review of results• Accelerates cash flow by getting more claims paid on first submission• Improves coder productivity with pre-coding review and recommendations• Reduces provider/payer/auditor medical record and claim review• Cuts overhead costs associated with claims rework and resubmission• Compares recommendations to a coded insurance form• Generates a claims analysis report highlighting variances and errors• More accurate claim submissions mean reduced rejections and denials

Access Integrity, Inc.4725 Indian School NE Suite 100Albuquerque, NM 87198accessintegrity.com

Medical Claims Compliance

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Medical Claims Compliance — Presentation Transcript

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