Claims Operations. An End to End Overview. An independent licensee of the Blue Cross and Blue Shield Association

Transcription

1 Claims Operations An End to End Overview An independent licensee of the Blue Cross and Blue Shield Association

2 Agenda Let s cover today. End to end Claims Flow From receipt to payment Great Successes in 2009 Things that made life easier Faster, faster What expedites claim payment Electronic Capabilities-HIPAA & Blue e What it can do to help 2

3 Typical Claim Experience Arrival of claims at our doorstep, and their validation Provider or Member Files Claim Receive Claim Process Claim Finalize Claim Provider or Member Receives Payment Provider claim Input Receive Electronically Electronic Claim Validate Data Received Electronically 94% Validated Data (claim can move to process mode) Blue e Paper Claim Member claim 837 Batch Paper Receive via USPS or FedEx Sort and Batch Scan or Key In Received on Paper Validate Data 6% Paper 3

4 Typical Claim Experience Commercial Business Suspended Claim Benefits and payment determination Provider or Member Files Claim Receive Claim Process Claim Finalize Claim Provider or Member Receives Payment Auto Adjudication Process Load on to Processing System First Level Processing (Batch) Processed Claim Validate eligibility Validate benefits Validate provider status Determine pricing Suspend Process (Second Level) Apply Policies and Procedures Perform Clinical Reviews COB Suspends Duplicate Claims Med Review Suspends Delinquent Accounts 4

5 Typical Claim Experience Commercial Business Application of payment to claims, and transfer of payments to providers and members Provider or Member Files Claim Receive Claim Process Claim Finalize Claim Provider or Member Receives Payment Finalized in 30 Days Processed Claims Finalize (Pay or Deny) Paid 99% Processed Claim Pre-payment Audits 90% Denied Perform Targeted Reviews Perform Audit (Random) 10% Adjusted +/- 1% of suspended claims 3% High dollar claims Member payments EFT Payments 25% Paper Checks 75% 5

6 Claims COB Improvements 2009 Category Change Denied Claims 51% Suspended Claims 32% Adjusted Claims 23% Members w/conflicting COB 64% COB Calls 16% COB Claims Quality Audit 1.05% 6

7 Payment Integrity 2009 Improvements FASTER Medical Policy Reviews/Record Reduction TIMELY Inventory Management ACCURATELY High Dollar Review/Sign off Focused Audits Random Audits Most efficient methods with fewer refund requests 7

8 Payment Integrity 2010 Efforts Improvements Data Mining Review of claims holistically instead of individually Detect errors faster Remediate recovery efforts to create consistent processes and payments and ultimately financial integrity Leverage advanced approaches and techniques Build more consistent claim payment practices Develop audits customized to BCBSNC s customer needs 8

9 Payment Integrity What can help expedite your claims? DME submit manufacturer s invoice not MSRP Submit unlisted drug code (NDC#, dosage, medication) or a procedure code Refer to our website to review the Corporate Medical Policy when submitting records for medical necessity Proper Coding Initially Correct Data Entry 9

10 Payment Integrity What can help expedite your claims? Use of Blue-e for authorizations, claim status File claims in full HIPAA standard format (837) Conduct an eligibility check on Blue e Include all necessary COB information Manage your clearinghouse reports Avoid duplicate submissions or paper submissions following EDI submission 10

11 Still a work in progress Continuing projects and improvements Continued work on 5010 More data matching for COB mismatches and discrepancies ICD-10 pre-work CMS eligibility clean-ups Increase of pre-pay audits Health Care Reform changes 11

12 Electronic Capabilities HIPAA Transactions & Blue e An independent licensee of the Blue Cross and Blue Shield Association

13 HIPAA Transactions Providers HIPAA Transactions Blue e Eligibility Verification Enrollment Benefits Health Eligibility Pretreatment Authoriz ation and Referrals 278 Precertification and Adjudication Authoriz a tion/ Case Status DIM Service Billing/ Claim Submission 837 Claim Acceptance CM S-1500 UB04 HIPAA 837 Claim Error Lis ting Claim Status Inquirie s Adjudication Claim Status Accounts Receivable 835 Accounts Payable Remittance Inquiry EFT 13 13

14 Blue e Health Eligibility and Benefits 14

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22 Blue e Authorization Request & DIM 22

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32 Blue e Clear Claim Connection (C3) 32

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37 Blue e CMS-1500 & UB-04 Claim Entry 37

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44 Blue e 837 Claim Error Listing 44

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48 Blue e Claim Status 48

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54 Blue e Remittance Inquiry 54

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60 Electronic Funds Transfer (EFT) 60

61 Electronic Funds Transfer (EFT) 61

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