One place to work all claims.
Claims Manager prepares claims ready for submission to payers in an ANSI HIPAA compliant format. Encoda retrieves these claims, imprints our proprietary “fingerprint” technology on each line item on every claim, then inputs these claims into Encoda’s Claim Scrubber. Offending claims are removed from the batch, and the remaining clean claims are submitted directly to the payers. Unlike a traditional clearinghouse which combines claims for multiple clients (many times hundreds of clients at a time), Claims Manager monitors each client’s payer submission individually for a corresponding acceptance (the ANSI 999 transaction). This transaction is typically available within an hour or two of submitting the claim file. Claims causing a rejected batch at this stage are automatically removed from the batch by BackOffice, and the claims file is resubmitted to the payer until an acceptance is received. Once claims files are received and accepted, Claims Manager then monitors each payer for individual claim status responses (the ANSI 277 transaction) and if no such response is received within a reasonable (client defined) time period, Claims Manager will trigger a claim status request, soliciting a response.
Claims Scrubber validates claims prior to submission to each payer, greatly increasing the likelihood of being paid in a more timely and accurate fashion. This can have a dramatic impact on total revenue and reduce the total number of days in accounts receivable. Fully integrated with your PM software, Claim Scrubber includes NCCI, LCD, NCD, and MUE rules, ICD-10/CPT mismatches, as well as identifying overlooked CPT codes. Also included are payer specific bundling and frequency rules, and custom demographic scrubbing which ensures that the basic elements of each claim are valid and correctly formatted.
Claim Scrubber will re-order claim charges based on client-specified rule sets, allowing the maximum reimbursement for your practice. Without halting the claim, Claim Scrubber can re-order the charges automatically. Common billing mistakes can be added to your claim scrub routines; these can then be displayed in Exception Manager for review or, in many cases, automatically fixed and submitted without user interaction. Claims Scrubber will reduce the amount of time your staff spends on claim review and working denials.
Exception Manager is a powerful, yet user friendly interface with a work queue that billing staff use to quickly view claims that require attention. This includes both claims that have been scrubbed and pulled aside prior to billing the payers and those claims that payers have rejected/denied that require possible rework. Encoda BackOffice captures all information sent to a payer and received from a payer over the life of a claim. All claim corrections and notes entered into BackOffice are automatically updated in your PM software. This enables your staff to quickly resolve claims, rebill, and move on to additional claims that need attention. The information corrected on the Exception Manager resolution screen not only fixes the claim but updates your PM master files so all future claims are addressed as well. This can eliminate thousands of potential claim errors. Additionally, claims can be routed by dozens of criteria to the staff member most qualified to handle the offending claim, and individual claims can be purposefully assigned to specific individuals with an audit trail of who assigned which claim, to whom and when.
Payment Manager monitors each of your payers for available remittance files and retrieves these files without staff involvement. Payment Manager interacts with your practice management software and payer data in a more profound manner than any other posting system. Payment Manager builds a dynamic relationship between claims forwarded to each payer and the insurance master tables in your PM software.
Payment Manager will:
- Confirm that 100% of claims/payments match
- Route payer denials to Encoda Exception Manager using advanced business logic based on payer ANSI remark/reason codes in combination with provider, procedure, payer, plan, allowed and paid amounts, and other remittance details.
- Enable advanced posting logic based on payer ANSI remark/reason codes in combination with provider, procedure, payer, plan, allowed and paid amounts, and other remittance details
Payment Manager catalogs all payer claim adjudication codes (CARCs and RARCs) and detailed denial analysis. Each code has associated actions that can be defined by the practice, allowing Payment Manager to automatically react to diverse situations.
Watchdog protects your system from billing loopholes, ensuring that your claims are pursued to the greatest possible degree. Whereas Exception Manager queues for your staff those claims that were flagged by the Claim Scrubber or claims that a payer has denied at some point in its lifecycle, Watchdog alerts staff when claims reach a threshold where something should have happened but did not happen. It can also create additional rules to monitor and react to problems in your billing system. Watchdog ensures that no claim is left behind and makes it possible for our clients to capitalize on every opportunity to collect revenue. As much as 10% of claims never make it to an explanation of benefits (EOB). Traditional practice management systems and clearinghouses regularly lose track of claims, improperly marking these claims as billed in the practice management system, with claims simply dropping into a black hole, having not been paid, denied, or adjusted. Issues of this magnitude grow progressively more difficult to correct as time goes by. Traditional medical billing software such as PMs are limited in scope, and unable to react to and report on events outside of standard reporting parameters. Only a preventative system, like Encoda’s Watchdog, can catch these problems before they become insolvable.
Maestro Analytics is comprised of two components, an always available (24×7) user-friendly, web-based dashboard that enables Encoda clients to access key financial and performance metrics using a PC, Mac, iPad, Android tablet, or mobile device using either iOS and Android devices, and a robust data mart containing every financial record ever processed by your billing software and every payer transaction that has passed through Encoda BackOffice.
Organizations that manage the revenue cycle for more than one medical practice can, with a single mouse click, view key financial and performance metrics cumulatively for all practices (aka all clients), a custom grouping of practices, an individual practice, or an individual provider.
Our analytics team is ready to assist you by creating the data extracts and analyses that clients require in order to most effectively manage their businesses. The Maestro Analytics data mart enables users familiar with Microsoft Excel to analyze a massive quantity of medical billing data quickly and easily. Maestro Analytics’ feed of data for pivot tables allows users to comprehensively analyze and report on data based on most any parameter within their system. In addition to analyzing financial performance, both the Maestro Analytics dashboards and data mart enable clients to understand how staff are performing. Dashboard examples below enable your management team to monitor the work being done in Exception Manager.