automating healthcare payment and claims remittance processing systemware's medical banking...
Post on 22-Nov-2014
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Automating Healthcare Remittance Processing
TAWPI Healthcare Payment Automation Summit
Chicago 9/14/09
Gordon Sellers Director, Healthcare & Medical Banking Solutions
gordon.sellers@systemware.com
Providers Landscape
• 7000+ hospitals, clinics, surgery centers, etc. • 450,000+ physicians in private practice
– Half in practices with more than 5 physicians
• Average 30% first pass denial rate per charge code – Half due to eligibility issues
• Average administrative cost per submitted claim – $10 to $12
• Average total administrative cost per secondary claim – $8 to $10
• Administrative cost for appealed claims – Can surpass $60
Source: Healthcare Financial Management Association
Why Medical Banking
• Currently banks provide: – lockbox services such as deposit of payments – imaging of checks – imaging of paper EOB (some)
• What banks could provide: – Data conversion
• of paper EOB’s into EDI 835 files for posting to Provider systems – Balancing
• of claimed amount with paid amount minus any adjustments – Process automation
• to reduce error rates and processing cost for Providers – Visibility
• into the relationships between claims, payments and deposits • Transactional discipline
Medical Banking
Extended HC Lockbox
• Medical Banking Application – Capture & indexing of EDI 837 files – Converts paper EOB’s into EDI 835 files – Capture & indexing of EDI 835 files – Automatic matching between EDI 835 files & EDI 837 files at the
claim and/or service line level – Output of targeted file for upload into PMS at Provider – Secondary / Tertiary claim preparation & submission – Exception Management workflow queues – Reporting
• Bank Administration Portal – Set up & Administration of Providers – Transaction Billing Report
Online Providers Experience
• Provider Portal (Bank Branding)
– Manage processing exceptions • 837 /835 matching • Secondary match to primary EOB image • Secondary match to 835
– Download posting file – Research denials for resubmission or
secondary – Dashboards and report generation
Copyright © 2009 Systemware, Inc. 13
Medical Banking
• What banks SHOULD provide: – Data conversion
• of paper EOB’s into EDI 835 files for posting to Provider systems – Balancing
• of claimed amount with paid amount minus any adjustments – Process automation
• to reduce error rates and processing cost for Providers – Visibility
• into the relationships between claims, payments and deposits – Transactional discipline
• banks have are good at this healthcare (providers) are not
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