Claims Repricing
To achieve the highest level of efficiency and accuracy, payors must eliminate as many manual processes as possible. IRP’s proprietary repricing technology eliminates these slow, error-prone processes to establish work flows that generate measurable cost savings. As an added value, our clients can maintain a HIPAA-compliant electronic data interchange (EDI) program to manage receipt, delivery and exchange of claims.
Features
- Repricing automation at 99.8 percent for clean claims with valid provider identification – virtually every managed care contract can be automated
- Batch claims repricing in two to six hours
- HIPAA-compliant EDI services
- Clearinghouse connectivity (Emdeon, ProxyMed, MISYS and others)
- Automated entry of claims into the system
- Automated provider matching
- Automated group/eligibility matching
- Automated repricing of DRGs, ASCs, APCs, per diems, stop-loss provisions, CPTs (including anesthesia modifiers), percent-off billed charges
- Automated receipt, delivery and exchange of claims
- Automated pre-adjudication files
- Paper-claim conversion to EDI
IRP’s easy-to-use solutions let you communicate efficiently through a single channel.
Benefits
- Low or no initial startup costs
- Substantial savings through control and reduction of repricing costs
- Improved reinsurance recoveries
- Dramatic improvement in efficiency
- Automation of the toughest 20 percent of claims, hospital and ancillary claims
- Immediate results that facilitate recoveries on high dollar claims due to "run out" on stop-loss reinsurance
- Unequaled accuracy
Contract Management and Modeling
With the IRP contract management, you don’t have to leave your desk to locate a contract or manage your contract inventory. And IRP handles tracking of effective dates and negotiations for you.
Contract management features
- View scanned and bookmarked contracts online
- Manage your contract inventory and directly link to contract images
- Track the IRP implementation of contracts and view the contract profiles
- Schedule reminders for yourself and others or use automatic e-mail alerts to track renewal dates
- Monitor provider performance and determine a contract’s bottom-line impact
IRP offers online modeling and analysis tools as well as outsourced contract modeling services. We have more than ten years of experience refining our systems and capabilities to better serve payors’ needs.
Contract modeling and analysis features
- Model contracts against real patient data
- Identify high-volume services
- Determine which services have high-dollar impact
- Model the impact of rate changes
- Compare modeled rates side-by-side to determine bottom-line impact based on a selected patient population
- Model proposed contracts against Medicare to establish a baseline
Electronic Data Interchange (EDI)
IRP’s EDI solutions power the seamless exchange of clean claims data among various trading partners. Our success is based on the flexibility and functionality of our systems.
Rather than purchasing an off-the-shelf translator, we developed our own ANSI X12 subsystem, which gives us greater flexibility than other EDI solutions.
That flexibility has many benefits. Through claims tracking, for example, we prevent lost claims by exchanging acknowledgments with all EDI partners. Based on our experience with custom formats and special situations, we’re able to import many different acknowledgment formats and track every claim we process.
Our system also addresses one of the major problems with the X12 format - any piece of missing data causes the entire claim to be rejected. We decided long ago that all-or-nothing claims were unworkable, and we’ve taken in every claim we’ve ever received. Claims that would cause problems after we pass them on are flagged and can be corrected using our online system. And we also apply a large set of automatic corrections to incoming claims.
IRP also has Edifecs, an X12 validation engine that helps us identify and flag claims with X12 and HIPAA errors. This error detection can be customized. And claims that would cause import problems in a trading partner’s translator can be flagged and worked online or dropped to paper.
Medicare Calculator
Medicare payment error rates reach as high as six percent of gross charges. Frequent changes in Medicare’s OPPS enhance the likelihood of faulty setup and table data errors.
IRP’s Medicare reimbursement calculators can help. These systems accurately reprice Medicare claims, including inpatient acute, outpatient, SNF, IRF and psych claims.
Outpatient Services
- Adjudicate all outpatient claims paid under any component of Medicare’s OPPS, including APCs; fee schedule items (lab, DME, prosthetics, orthotics, perenteral and enteral nutrition, PT, OT, and speech pathology); device pass-throughs; pharmaceutical and biological pass-throughs; and outliers
- Skip the process of grouping claims. We run each claim through our licensed grouper to assign APCs, flag reduced payments (for certain multiple procedures), and apply edits (e.g., Outpatient Code Editor (OCE) and National Correct Coding Initiative (NCCI) edits)
- See online how each line item on the claim is adjudicated
- Calculate both the Medicare payment and the patient co-payment
- Generate logs to facilitate your cost reporting
- Design reports that meet your unique requirements
- Using the patient’s demographics and charges, see the expected payments and any OCE/NCCI edit errors in a matter of seconds
- Generate the payment details that others may fail to provide if they have not migrated to the latest EOB (a remittance advice)
- Reprice any APC claim, as our system was set up August 1, 2000
Inpatient Services
- Process inpatient, acute, psych, skilled nursing and rehab claims
- Use multiple filtering criteria for reviewing cases
- Enter a DRG, gross charges, and a discharge date to receive the expected payment, including all special factors--Indirect Medical Education (IME) Disproportionate Share Hospital (DSH), Sole Community Hospital (SCH), Medicare Dependent Hospital (MDH--and outliers, etc
General Benefits
With IRP’s Medicare calculators, you can monitor the impact of code assignments, forecast the impact of scheduled changes and estimate patient co-payments. Our Medicare repricing can help you accurately reprice claims based on the most up-to-date fee schedules. And the expected payments feature lets you review physician practice patterns, analyze variations in payment for the same DRG from one Medicare year to another, or research denied, rejected, returned, or suspended claims.
Our professional staff, which includes several HFMA-certified financial professionals, is available by phone and e-mail to answer questions and provide assistance.
