IntelliClaims 360


US Healthcare industry is plagued by high administrative costs, that in turn reduces the effectiveness of the $ spent on healthcare. Based on available statistics, 30 cents to a $ spent on healthcare overall goes towards administrative costs (both at provider and payer). The bulk of this administrative cost goes towards claims submission, processing (incl. adjudication), processing of payment (still a high percentage in manual) & final reconciliation.  One key factor that contributes to the high administrative overheads is the fact that a large percentage of claims processing is still manual, thereby prone to errors & resulting in repeated submissions of the same claim. From a providers perspective, this leads to unpredictability in cash flow, which in turn impacts the operating margins.

The other major issue plaguing the provider is Bad Debt (esp. from patients – both for self-pay and the amount due after payer settlement). One of the contributors is the lack of visibility into the status of claims & therefore timely billing of patients for the residual amount due to the provider after settlement by the payer. Any collection of these long pending/outstanding claims will help cash flow & improve margins (by reducing the amount of bad debt).

IntelliClaims 360 – a Business Intelligence solution provides access to actionable insights using Key Performance Indicators and metrics to help improve provider’s revenue cycle management. The solution enables you to identify key metrics such as denials, underpayments, contractual adjustments and patient outstanding which represents most of the monies that is left uncollected.

IntelliClaims 360@Cloud – a similar solution as IntelliClaims 360  but deliverd on a subscription basis where customer pay using ‘Pay As You Use” model. This helps small healthcare pratcices to avoid huge upfront investments.

The solution enables advanced analysis of end-to-end claims processing to understand process bottlenecks. This helps you to find out areas where action needs to be taken to increase the rate of first pass approvals. Comprehensive Denial Management helps in process optimization to reduce rework/resubmission. The solution also provides insights in the status of claims – using historical trends helps predict cash flow incl. probability of claims realization. These insights enable the provider to focus on initiatives to improve process efficiency and thereby reduce costs.

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In essence, the solution can answer the following questions for providers and do more…

Predict Cash Flow

  • When is cash expected against a claim?
  • How much is expected from a claim?
  • How much of revenue is at risk?

Monitor Operational Performance

  • How does a department impact cash flow?
  • Why is there an increase in DNFB days?
  • What is the billing team’s productivity?
  • What does it cost to collect a claim?
  • How much time is spent on resubmissions?

3600 View of Payer Performance

  • Is your Top Payer the Best Payer?
    • Score and Rank payers objectively
    • Customizable Performance measures & weightings
  • How do different payers stack up?
    • Avg. time for payment
    • Current status of all outstanding claims
  • What is the trend of percentage of claims denied?
  • What are the top reasons for denial?

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This solution integrates with other business systems and presents near real-time claims information through an intelligent dashboard. Providers now have ready access to actionable insights using Key Performance Indicators and metrics to help them achieve their business goals.

The solution uses time-series analysis and predictive models to provide visibility into expected cash flow while highlighting revenue at risk, based on probability of claim realization. The solution also enables advanced analysis of end-to-end claims processing to understand process bottlenecks. These insights enable the provider to focus on initiatives to improve process efficiency.

The solution enables effective and objective measuring of Payer performance using a custom built scorecard based on key metrics. The 3600 view of payer performance allows comparison and trend analysis of these key metrics with other payers, while providing insights into operational areas like process times and effort spent in processing a claim. This holistic objective view of payer performance can help with better contract negotiation.

The solution provides metrics to understand productivity prior to implementation of ICD-10 which can be used as a goal to get back after the implementation. As denials are expected to increase after ICD-10 implementation the solution can help you identify the top reason for denial enabling you to take the right action with the right responsible party – payer or the billing team.

Benefits

  • Provides visibility in to key metrics to efficiently manage the revenue cycle and improve cash flow
  • Uses time-series analysis and predictive models to provide visibility into expected cash flow while highlighting revenue at risk
  • Enables you to monitor the metric trends against pre-defined goals
  • Provides a way to manage denials by identifying reason codes and procedures triggering denials
  • Helps identify complex claims with multiple payers such as Primary, Secondary and Tertiary
  • Supports effective payer contract negotiation by providing a set of tools to compare payer performance including a Payer Score Card
  • Enables comparison of billing charges against payer fee schedules to identify if billing charges need to be adjusted
  • Ability to predict the likelihood of claim realization using statistical model and forecast cash inflow from claims