Claims Editing

HOW WOULD YOU LIKE TO PERFORM CONCURRENT REVIEW ON 100% OF YOUR CLAIMS EVERY DAY WITHOUT ADDING ANY FTE'S?

The OCExaminer solution provides web-based claims editing.  This allows hospitals to submit their claims to us and forget about them.  If we find a problem, we'll let you know and help you fix them through our proprietary applications.  We send the clean claims on to the carrier for adjudication.  But that's just the beginning...

We have 3 levels of edits--all controlled by the user. 

First, we offer all of the Medicare edits--are the CPT codes current, is the sex of the patient consistent with the procedure--all of the issues that would prevent the claim from being paid in full the first time.  But there's more.  Are there issues on your claims that would hit a flag for a RAC audit?  We identify these separately from the standard Medicare edits so that you can review them later to make sure that all of your "I's are dotted and your T's are crossed".  We can even perform a "look-back" through all of your previously submitted Medicare claims.

Next, we have built edits that are universal to all payors.  We look for companion codes--did you bill both "pieces" of your Interventional Radiology procedure?  Some payors pay for the technical component and some pay for the procedure.  If you don't have the right one on the bill, you don't get paid anything.   We look for procedures that require high-cost devices--if you inserted a pacemaker, did you bill for the device as well as the procedure?  Are your injection codes correct?  Did you charge for your infusions?

Finally, we give you an area where you can write your own edits, based on your particular managed care contracts.  This functionality is designed to capture the unique elements of your managed care contracts and ensure that payer-specific items are evaluated for coding and billing accuracy prior to submission to the payer.   Do you have a stop-loss limit for Humana?  Do you want to look at claims very close to stop loss to find additional charges?  Do you have a payor who requires a certain Revenue Code (different from the norm) in order to pay for an item?  You tell us how you want to handle these claims.  We can submit them as they are, and flag them for you, or return them to you for additional processing.  It's entirely up to you!

We have dedicated staff to maintain all of the edits, thereby allowing your billing staff to simply submit the claims file and work the rejections through our user-friendly UB application.  All of the processing takes place on our secure servers and is completed within hours of submission.

You decide which edits you want to use and you decide how you want your claims handled.  We do the rest.

Detailed OCExaminer Presentation (15 Minutes)