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Medical Claims Compliance
The document discusses the challenges of medical claims compliance, highlighting issues such as fraud, denial rates, and the financial impact on healthcare providers. It presents a comprehensive analysis of medical transactions that employs technology to improve compliance and efficiency in claims processing. Key product features include validation of coding, fee calculations, and compliance checks, aimed at reducing rework costs and expediting claims submissions.
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Medical Claims Compliance
- 1. Medical Claims Compliance™ Comprehensive Analysis of Medical Transactions Data Harmony Users Group John Kuranz CEO Access Integrity, Inc. February 8th, 2012
- 2. Medical Claims Compliance™ Comprehensive Analysis of Medical Transactions Problem Process Product
- 3.
- 4. 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
- 5. Process Comprehensive Analysis ofMedical Transactions
- 6. Physicians, Group Practices Hospitals, Clinics PA’s, NP’s & RN’s Nursing Homes Services Providers $$$ 1,200 Payers 300 Million Patients 700,000 Providers 1+ Billion Patients Records 53+ Million Procedures 4+ Billion Claims
- 7. Physicians, Group Practices Hospitals, Clinics PA’s, NP’s & RN’s Nursing Homes Services Providers $$$ 1,200 Payers 300 Million Patients 700,000 Providers 1+ Billion Patients Records 53+ Million Procedures 4+ Billion Claims
- 8. Product Apply an existingtechnology to a new application
- 9. Medical Claims Compliance Useruploads single or report shows coding and batch of claims for billing error. verification Access Integrity AI2 Server Business Logic (M.A.I.) Validate form and note information
- 10. AI2 Claims Processing 837Data Form 1500 AI2 Reports Error Types Electronic Health Records Error messages Physicians Notes Etc. ETL and Enrich with Metadata Extractor XML Repository Machine Aided Export data Indexer (M.A.I.™) XML CPT CSV HCPCS ICD 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
- 11. Medical Claims Compliance Health Information Network
- 12. 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
- 14. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help
- 16. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help
- 17. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help INDICATIONS FOR SURGERY: The patient is a 10-year-old white female child with a history of chronic tonsillitis refractory to medical therapy. She was taken 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 CPT General endotracheal anesthesia. SPECIMEN: codes resulting from a Tonsils and adenoids. FLUIDS: Crystalloid. review of physician and COMPLICATIONS: None. procedure notes ESTIMATED 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 endotracheal tube. Intravenous ampicillin and Decadron were administered. She was placed in the rose position. A Crowe-Davis mouth gag was inserted. The adenoids were removed with the adenoid curet. The nasopharynx was packed. The tonsils were removed using electrocautery to dissect between the superior constrictor muscle and the tonsillar capsule. Hemostasis ICD9 code was achieved with suction cautery. With adequate hemostasis, the pharynx was irrigated and suctioned free of CPT code secretions. The stomach was emptied free of secretions. She was awakened from anesthesia without difficulty.
- 18. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help This is a 70-year-old female who has a history of symptomatic ventral hernia. She was advised to undergo laparoscopic evaluation and repair. The risks and benefits including bleeding, infection and cardiopulmonary complications were discussed 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 the subcutaneous tissue. The abdomen was insufflated with C02. Two 5 mm trocars were placed, one in the left upper quadrant 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
- 19. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help
- 20. Submit Claims Review Claims List of Batches Search for Claims Edit Claims Admin Help
- 21. Complete Analysis Medical ClaimsCompliance checks each submission and produces detailed 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
- 22. Provider Benefits • Reducesrisk 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
- 23. Access Integrity, Inc. 4725Indian School NE Suite 100 Albuquerque, NM 87198 accessintegrity.com
Editor's Notes
- #15 Select your file format then specify a date range and run your files
- #16 Files can be selected from either your local storage facility or our cloud based application which is part of your annual subscription
- #17 A message from our server confirms receipt of your files and notification will be sent to your email address when records and claims will be ready for review.
- #18 Prior to claim coding, Medical Claims Compliance will automatically review the physician and procedure notes and provide suggested thesaurus terms from our rule based datasets then provide suggested ICD-9 and CPT codes
- #19 Medical Claims Compliance allows you to enter procedure and diagnostic codes while looking at highlighted physician and procedure notes..... all simultaneously and prior to completing your claim.
- #20 Medical Claims Compliance scans medical/surgical reports and generates a claims analysis which recommends appropriate coding for your insurance form. It generates a claims analysis pointing out differences and explaining errors whichboosts accurate claim submissions, reducing reviews, denials and rejections.
- #21 Medical Claims Compliance gives healthcare providers the ability to review and correct all flagged claim forms prior to submission.