Claim Depot


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Claim Depot

  1. 1. CLAIMS DEPOT Product Concept Paper by Rahul Sethi Dated: 11/21/2010 BY INTEGRAL FUSION
  2. 2. A write up on Claim Depot Introduction Claim Depot is a group of products which manages workers’ medical compensation claims. It consists of four products specifically designed to manage the expenses associated with lost-time claims: • Metaclaims – a medical claims’ archiving and management system • Managed Medical Audit – a medical bill audit system • Medical Management Services • Managed Provider Network These products can: • Significantly reduce expense on claims • Reduce your operating expenses • Identify possible fraudulent claims, and • Limit your exposure to compliance penalties Metaclaims Metaclaims is an Internet based document archive and medical management system. The Metaclaims application allows real-time access to electronic claim files to workers’ compensation stakeholders such as: Claims Examiners, Nurse Case Managers, Payers, and Defense Attorneys. Metaclaims is the repository of all types of electronic files: • Images of claim documents can be stored as PDF or TIF files • Audio recordings of depositions, • Surveillance videos, and • Digital photos etc. Access based on user permissions can be had at the touch of a button. Documents are stored chronologically, and indexed appropriately to facilitate easy access. Users can add additional information, allowing them to efficiently manage their files. Users can directly upload electronic documents into a claim file for real time updating. This dramatically reduces overheads incurred on storage, mailing, filing etc.
  3. 3. A write up on Claim Depot The Publish feature allows access to specific documents to authorized external parties. This feature can be used to provide legal documents to a plaintiff’s attorney, prior treatment reports to a medical provider, and any other type of document to parties authorized to receive information from a claim file. By using this method of document distribution, claims administrators would see substantial savings in copying costs and delivery fees. Documents can be published to valid e-mail address. The system generates an e-mail advising the requester that he has been granted access to the documents for a specified time. He is given a temporary password for this purpose along with a link to the relevant Metaclaims site. They could then use the temporary password to set up their own personal password. Thereafter, upon login he would be directed to the specific documents authorized to him for access. Additionally, any message the examiner had annotated would appear above the documents. The requester could then view and print the documents during the time period that they were granted access. The system maintains a log of all access in terms of users, date, time, and activity. Medical Claim Audit and Management The Metaclaims system also contains claim management and reporting capability. Examiners can request an authorized nurse case manager, doctor or attorney to review a specific file and provide a report. The system notifies the authorized party that they have received a request for a review. Upon acceptance, they are given direct access to the claim file documents. The reviewers can make notes as they go through the documents. If the documents are PDF files, Adobe Acrobat can be used to copy and paste information directly from the documents into the notes, saving time and effort. When all documents in the file have been reviewed, the notes are compiled by the system to create a report. When the report is finalized it is placed into the claim file, and a notification is sent to the examiner. By using this feature, the client ensures that reviews are handled in a timely manner and virtually eliminate the possibility of compliance penalties. The system maintains an audit trail of access to published documents and notifies the examiner when any authorized external party accesses the site. Managed Provider Network The system also caters to a Managed Provider Network (MPN). To ensure compliance with state regulations, we have developed an intake process that is specifically designed for each client. Intake tracks and generates all required stakeholder mailings, and then at transaction completion, delivers copies of all documentation into the appropriate claim files. With so much of change occurring in the claims administration environment, the intake process provides a methodology to comply with the myriad of state regulations governing MPNs. We are experts in the workers’ compensation arena, and take pride in the cost containment solutions that we offer. Our Managed Medical Audit system allows us to create specialized management reporting
  4. 4. A write up on Claim Depot that can be used to assist with fraud detection. By analyzing the treatment data contained in our bill review data bases, our nurse case managers can identify claims that show signs of potential abuse. Authorized parties are given concurrent access in real-time, allowing more in depth claims analysis. Calls can then be made to providers and claimants to verify treatment rendered visavis treatment reported. Inconsistencies can then be noted, verified, challenged, and passed to the appropriate authorities. The combination of Metaclaims and Managed Medical Audit is the perfect tool to assist stakeholders in detecting, and reporting fraud. The Claim Depot group of products enables payer’s to actively monitor their claims process, and to do extensive outcomes analysis of their MPN provider panel. The paperless application platform not only reduces expense, it also speeds the claim closure process by providing real-time communication to all parties involved with managing a claim. Why Go Paperless? By enabling claims personnel, employers, and various compensation service providers open access to claims documents/data, insurers, self-insured, and claims administrators can finally begin to change the archaic and restrictive processes that have severely constrained the proper administration of claims. The following are possible benefits streams: - 24/7 Internet information access promotes a virtual operating environment positively impacting space, storage, and personnel costs. - Employee productivity can be enhanced 200% - 300% with instant data access, and enable telecommuting realities. - Data as well as electronic files can be moved to stakeholders e.g. lawyers, physicians etc. within seconds, thereby dramatically reducing copying costs and improving the timing and scheduling of communication. - Medical professionals can begin the managing of claimant medical treatment with ease from their office locations with greater productivity and in concert with accepted industry treatment protocols, positively impacting rising medical costs. - Claims oversight can be vastly improved allowing supervisors to better manage examiners in a real time mode. Additionally, the headaches of examiner turnover, with full claims document access, can be minimized to a 30 day process from the traditional 4 -6 month ordeal. - All in all, the benefits of improved speed, oversight, and communication are a given with this new technological approach, and further, finally enables the claims administrator to develop a process flow to fit their organizational needs, competencies, and structure.