- Problem : Designed to adjudicate and produce a single response (endpoint)
- Problem : Difficult to deliver and track claims upstream to payors
- Problem : Refunds, payment reversals, and resubmission always a challenge
- Problem : Extensive configuration and maintenance
- Problem : Inflexible pricing methodology
- Solution : Store provider claims directly from their practice management system
- Solution : Maintain balances for the provider (AP) and balances for the payor (AR) separately
- Solution : Immediately submit these same claims to the payor with minimal scrubbing to avoid timely filing delays
- Solution : Track the payor claim and the provider claim separately – payments and adjustments react together to payor input
Track Accounts Payable (AP) and Accounts Receivable (AR)
Many of our clients have a need to price claims based on custom contracts with both the payor and provider. This could be a risk based per member, per month contract or simply a fee for service based contract. Prices for claims are defined when they are received from the provider. Defining what is owed to the provider versus what the payor owes up front means that you can track both sides of your accounting with ease.
Flexible Contract Management
We create a well-defined set of rules for claims pricing and administration fees. These rules are not limited to static fee schedules. We have the capability to expand the schedule by effective and term dates, percentages, and other custom rules without the need to duplicate large fee tables for any special cases.
The contracts and fee schedules are easily managed using online tools that are able to address these common issues without making a mess of your data. The editors typically support custom contracts for fee-for-service schedules, risk based contracts, bulk import and other special case rules.
Our systems are capable of pricing claims based on DOS, strict contract amounts, billed amounts, or percentages of these amounts. We also have rules designed to handle risk or pass-through claims that need no pricing other than the ability to track what is owed in COB or patient responsibility balances.
