Our client, a unique next-generation PPO network was the first network to incorporate the ePPO Program (Patent Pending). The ePPO Program combines evidence-based medicine (EBM) with a pay-for-performance incentive system to improve the quality and affordability of health care.
Claimshop® was called on to become this client's technology partner – to develop and maintain repricing automation for over 116 (and growing) evidenced-based medicine guidelines with multiple potential reimbursement methodologies. Also, the client required a Web Services (real-time) system interface.
Claimshop was also called on to develop and maintain a HIPAA-compliant EDI claims receipt and delivery environment so that all claims could be electronically submitted by providers for repricing and sent electronically to payors for adjudication.
Further, Claimshop was called on to provide Internet-based repricing, access to claim histories and reporting for the client's payors and providers.
Solutions Delivered by Claimshop
Claimshop analyzed the client's processes, determined where improvements could be made and delivered the following solutions
- Inbound and outbound HIPAA-compliant EDI
- Parallel test environments (so proposed contracts could be modeled and compared)
- Automated group/payor and provider matching
- "Stratification" (sub networking and tiering of items to be processed)
- Interface with scanning vendor
- Online, real-time repricing capability
- Claims tracking and audit trail capabilities
- Claims repricing automation for Evidenced Based Medicine guidelines
- Conversion of Paper claims to EDI.