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How to Handle Complex Claims More Effectively

How to Handle Complex Claims More Effectively

Modernizing and streamlining claim adjudication has never been on the back burner for healthcare payers. Rather, they’re continually faced with the challenge of driving efficiency and innovation while simultaneously maintaining payment integrity as the claim processing environment increases in complexity.

With modern-day technology at the helm of the healthcare system, it only makes sense to fine-tune claim processing using those same cutting edge resources. The only caveat is that not all claims should be treated equally; particularly for those members receiving treatments for complex and expensive conditions.

Prolonging the claim life cycle are complications in the assessment phase—often flying under the technical radar. To be more specific, complex high-dollar claims are often “red flagged” or routed to Senior resources manually without the clinical and financial insight required to properly inform decisions.

However, we offer a ground-breaking solution, harnessing the power of technology and empowering payers to handle complex claims more effectively.

Understand the Processing Issue

Possibly processing millions of dollars worth of claims daily, claim adjudication poses a great deal of risk for payer organizations. Aside from ensuring internal controls and providing effective operations, their main job is to control the way a claim is handled.

It seems straightforward enough, right? Often overlooked is that the underbelly of claim adjudication and managing healthcare costs can be somewhat of a maze.

For example, although most claims are transmitted electronically, some are occasionally still processed manually. Unsurprisingly, it’s the high-dollar complex claims that use up all the paper.

Furthermore, the risk of oversight is tremendous. After all, it’s not always easy to identify questionable claims. Analyzing for reason codes alone can prove to be incredibly time-consuming.

With that being said, automated task assignment often shuffles right out the door. Brazenly waltzing across the desk of Senior adjusters, at the same time, are tedious administrative functions. In short, it typically requires a lot of time and effort to handle complex claims.

Clearly, electronic processing isn’t a one size fits all. Yet, it’s worth it to give detailed attention to the low percentage of claims categorized as complex.

The Challenge of Flagging Complex Claims

One of the most significant drivers of healthcare costs is the handling of complex claims. Yet, employing thorough claim review serves as an effective loss control measure.

It may seem like a simple enough solution. In many cases, however, it’s not always clear which claims warrant further review. Moreover, analyzing claims at a glance—like a snapshot of overall risk—has been only a fantasy until now.

How to best handle complex claims is an organic issue as the landscape for treatment and expected cost is continuously changing. To strengthen oversight, it’s helpful to see the indicators from a bird’s eye view. We’ve identified factors that the experts advise “red flagging” in this article here.

From end-to-end, it’s becoming necessary to read in between the lines, per se—to analyze a complex claim as well as predict risk.

How to Employ Smarter Data Analytics

The paper shuffling, switching to and fro within multiple screens, and inefficient task assignment can all end with smarter data analytics.

We’re empowering payers to make smarter decisions with revolutionary transactional surveillance and software reporting tools for catastrophic claims oversight. In short, we believe we will forever change the way high-dollar claims are processed and analyzed.

Predict FACS

FACS is our proprietary Financial and Clinical Surveillance platform. It’s the first post-adjudication, pre-pay claims surveillance system of its kind to identify the claims that need additional review.

Having a precise focus on complex issues, this platform easily identifies questionable claims with reason codes. In fact, its aim is targeted on particular claims requiring advanced detection analytics beyond typical claim system and code editing capabilities.

Part of our Predict Suite, FACS focuses on the affordability of care by combining our advanced analytics, technology, and intelligence of the entire platform. The best part? FACS gives near real-time response rates pre-pay/post-adjudication with minimal IT requirements in a cloud-based solution.

Predict Profiler

Our Predict Profiler provides a complete risk profile, delivering risk feedback on claims. Additionally, it breaks down the recommended treatment and associated specialty pharmaceutical costs of high-dollar diseases and high-risk individuals.

This is a simple, non-intrusive, and cost-effective way for payers to provide robust Trigger Reporting to their carriers.

When reviewing aggregate exposure for potential risk—whether on new business or renewal—Predict Profiler streamlines the total aggregate claims run in a very easy, multi-level view. It’s the bird’s eye view payers have been waiting for.

For a demo on these revolutionary tools, please contact AMS today.

 

Resources:

https://www.shrm.org/resourcesandtools/tools-and-samples/toolkits/pages/managinghealthcarecosts.aspx

https://www.mdstrat.com/what-makes-a-complex-claim/

https://www.mdstrat.com/directories/predictfacs/

https://www.mdstrat.com/directories/predictprofiler/

https://www.mdstrat.com/contact/

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