CLAIMS
SCRUBBER SEMINAR
CLAIMS ADJUDICATION
Tired
of costly errors? Develop your claims scrubber
A
claims scrubber module represents the most vital cost containment tool for
payers and TPAs in adjudicating claims from healthcare providers and for IPA and
MSO analyzing claims paid by HMOs. Millions
of dollars can be saved!
Also
a claims scrubber with pricing capabilities can simplify the job of Case Managers
estimating claims of services rendered by providers that are considered
“out-of-network”
Our
HPP AccuChecker team has developed seven (7) claims scrubbers systems in the
last fifteen years – we learned that you can develop a claims scrubber in 60 to
90 days if you have a team of programmers and healthcare reimbursement experts
working together. It is understood that an
adequate training session 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 anesthesia,
surgical, medical, diagnostic and rehabilitative services as well as supplies,
DME and orthotics
·
On
inpatient admissions observe that there is only one admitting physician and
that double charges for surgeons, 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
No comments:
Post a Comment