e Medical Claims Software & Health Claims Payment Processing Software | Managed Care Systems, INC
 


Success Story
A smooth transition to IMPACT.
 

Case Study:  Rules-Based System Improves Productivity and Saves money at Health System's Payer Division

Executive Summary

The payer division of a large health system used an antiquated processing system to administer the system's employee benefit plan.  The system also managed several preferred provider organization (PPO) networks and capitated health maintenance organizations (HMO) plans.  The existing processes were highly manual and inefficient.  By implementing IMPACT, the flagship product of Managed Care Sytems, Inc. (MCSI), based in Phoenix, Arizona, the health system configured a software solution to meet their unique business requirements and accurately expedited claim payments improving its relationhip with both providers and employees.

Background

The incumbent system was a non-HIPAA compliant system designed primarily to manage capitated plans.  The health system searched for a claim management software solution that was HIPAA compliant and that could automate existing business requirements without excessive and ongoing vendor involvement.

Problem

In order to provide excellent service to the health system's providers who employed the plan participants and received the plan payments, the health system needed a highly flexible system that could be controlled and maintained by in-house users within the confines of a cost effective migration to a new system.

Solution

A detailed analysis and functional review of several vendor's systems led the health system to choose IMPACT.  The cooperation between the health system's IT department, payer division's business personnel and MCSI's implementation team led to a smooth implementation that tranisitoned nicely into the health sytem's ability to take over all functions, major and minor, of the IMPACT system.

  


 

 

MCSI's practice of including all source code with system purchase engendered a sense of perpetual confidence in the health system's IT staff, and the rules-based approach to auto-adjudication provided the business personnel control over their own destiny with regard to implementing changes.

In addition to automating existing HMO, PPO and point of service plans, the health system's payer division developed new lines of business, becoming the administrator for the group's mental health benefits.  This line of business was previously outsourced to a specialty claims handling organization.  IMPACT's rules-based auto-adjudication made the transition to in-house claims handling quick and painless.

More than merely becoming HIPAA compliant through the implementation of IMPACT, the health system capitalized on the usage of HIPAA transactions (837 - claims, 277 - claim status, 278 - healthcare services review, 835 - remittance advice and 834 - enrollment) in order to share data with all the consistency and ease envisioned by the HIPAA authors.

Web-based inquiries for claims and enrollment reduced customer service calls as patients and providers began to self-serve.  Web-based data entry of authorizations and referrals streamlined the review process.  Integration with other technologies such as scanning/OCR and SQL data warehousing lifted the burden off the health system's IT staff and increased operational efficiencies for their business personnel.  Reporting, once a difficult, highly technical process, was greatly simplified and is performed by junior staff members.  The end result is a hightly efficient claims organization that approves over 97% of clean claims within 24 hours of receipt and takes on new business without trepidation.