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Medical Claims Processing Case Study

Medical Claims Processing Case Study

EBC is headquartered in Milwaukee, Wisconsin – with five operations centers located around the country. Their primary goals were to centralize their front-end work and reduce costs – through a data-capture partner and an EDI scrubbing package. A secondary goal was to integrate an enterprise-wide content management software system.

Solution

First: OnCourse provided a front-end solution that centralized the mailroom, sorting, scanning and data capture through our office – easing staffing and training issues and eliminating the need for multiple-location scanning equipment. Capacity has been increased, and costs have been reduced. After claims have been keyed, data file is transmitted to EBC via Secure FTP.

Second: ValiData – our software partner – installed a data-scrubbing package to pre-process the EDI. Claims data is now run through a robust matching and validation process that significantly increases auto adjudication rates.

Third: Scanned claims are uploaded to the FileBound Content Management Software – providing web access to the claims for all offices.

All back-up requirements have been met, and SAS70 certification has been achieved.

Outcomes

  • The front end process is simplified
  • Centralized mail processing provides greater consistency
  • Scanning and Data Capture are consistently completed in 24-48 hours
  • Pre-processing software increased matching and auto adjudication rates
  • All claims are processed with the same rules
  • FileBound ASP enables access to the claim images from anywhere
  • FileBound provides solutions for projects other than claims (W9's, checks, etc.)

Process Overview

  • Claims mail is forwarded to OnCourse
  • Claims are opened, sorted and scanned within 4 hours
  • Data Capture is performed and output in ECSIF or ANSI 837 4010
  • EDI is processed with ValiData prior to importing into QicLink
  • Claim images are indexed and uploaded to FileBound ASP
  • Claims Data is sent to EBC and preprocessed with ValiData software

Advantages

  • Reduced costs
  • All claims for all offices are processed timely and consistently
  • Productivity and efficiency is greatly improved
  • No additional hardware is required to support the FileBound software
  • Labor savings and reduced training