Managed Care Boot Camp
Utilizing Managed Care Claims Data
Effectively for Improved Revenue
Presented By:
Kerry Elledge
Quadax, Executive EDI
5/16/2013
Managed Care Boot Camp
Introduction: Quadax
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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
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Managed Care Boot Camp
Claim Life Cycle - EDI
• Claim Drop – From
Host System
• Scrub-A-Dub Dub:
– Edits: Payer, NCD,
LDC, CCI, MUE, OCE
– Edits: Custom
Cleaner
claims
Faster
reimbursement
Better
cash
flow!
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Managed Care Boot Camp
Claim Life Cycle - EDI
• 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
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Managed Care Boot Camp
Key Managed Care Points
• Medicare No-Pay Claims
– HIC #
– Condition Code
• Medicare/Medicaid Edits
applied to Managed Care
Plans
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Managed Care Boot Camp
Key Managed Care Points
• 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)
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Managed Care Boot Camp
Key Managed Care Points: Automated Secondaries
• Claims are processed more quickly - You receive
payment faster
• You’ll be aware of denials sooner with greater
opportunity to reverse
• Key savings opportunities
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No longer paying postage
No longer have to pay for the forms
Save employee time of manually creating secondaries
Streamlined follow-up
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Managed Care Boot Camp
Key Managed Care Points: Denial Management
Where do denials come from?
Scheduling
Service
Collecting
Payment
Billing
Service
• Effective denial
management strategy
Providing
Service
– Identify, Classify, Quantify
– Manage Denial Follow-Up
– Prevent Denials Through
Process Improvement
– Develop Effective Reporting
Coding
Service
Any and all points in the revenue cycle
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