Medical Claims Processing

The outsourcing of Medical Claims processing continues to grow as the healthcare regulations become more complex. A key element to making this process efficient is the ability to classify documents as soon as they arrive at the claims processing facility. This means converting to data as quickly as possible then performing the required functions. The applications, which drive the front end of the claims process, must be able to perform the following activities quickly and efficiently:

EDI scrubbing services
ValiData Provider and Eligibility matching services
Create “Provider Load” from EDI Claims
EDI File Conversion – ANSI 837 to Proprietary & Flat File
Claims processing for Institutional / Professional / Dental / Vision / Work Comp
Custom rules and rejection handling
Develop and host EDI connections to partners
Database cleansing
Paper to EDI – Mailroom /Scanning/ Data Capture Services

Medical Claims Processing

OnCourse helps streamline the front-end claims workflow far a Large Midwest based TPA.

Overview

The customers primary goal was to streamline the front end of both their EDI and Paper claims. The ability to perform Provider and Eligibility matching prior to loading claims into their system was essential to the project. Additionally, they wanted the ability to route claims to a number of trading partners prior to loading into their Claims software. A second initiative was to outsource their entire paper claims process including Mailroom, Scanning, Data Capture & Document Management Software.

Solution

A proprietary OnCourse service called ValiData was implemented to perform Provider and Eligibility matching. Claims data is now run through a robust matching and validation process that significantly increases auto matching rates.

OnCourse provided a front-end solution for mailroom, sorting, scanning and data capture. This eased staffing / training issues and eliminated the need for scanning equipment. After the data capture is performed; the claims move through the same workflow as the EDI claims.

Scanned claims are uploaded to the FileBound Content Management Software; providing web access to the claims for internal and remote employees.

Process Overview

EDI is routed to an OnCourse Secure FTP.
Claim mail is forwarded to OnCourse.
- Mail is opened, sorted and scanned.
- Data Capture is performed and output in ANSI 837 5010 (EDI).
All claims are processed with ValiData prior to importing into Claims System.
Claim images are indexed and uploaded to FileBound.

Outcomes

The front end process is simplified.
Turnaround times was significantly reduced.
Scanning and Data Capture are consistently completed by the next business day.
Pre-processing software increased matching and auto adjudication rates.
- Clerical time was cut by 80% for managing “no match” claims.
FileBound enables access to the claim images from anywhere.
FileBound provides solutions for projects other than claims (W9’s, checks, etc.).

Advantages

Reduced costs.
Labor savings and reduced training.
Productivity and efficiency is greatly improved.
No additional hardware or software development was required.

Application

Accounts Payable

The benefits of invoice approval automation are widely known, however finding an affordable solution that is easy to use, enterprise wide, and can be modified to adhere to your specific business rules and processes can be hard to find. An OnCourse solution checks all of those boxes as well as eliminating the manual capture processes by your team through integration with your ERP.

An OnCourse solution meets you at your point of need; from invoice receipt that allows your vendors to seamlessly continue to submit invoices without change, to indexing the required fields backed by extensive quality control verification from your databases. Using a permissions based approach, access and actions are defined by your rules, not software limitations. Approval routing can be fully automated, ad-hoc direct to approver, or any combination. Escalations can be built in and a detailed audit trail is standard. Let us help you configure a solution that gives immediate visibility to your entire spend.

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