California Based MSO Improves Claims Processing Efficiencies and Cuts Costs with MedValue

Challenge

A premier California Management Services Organization (MSO) providing services to health care provider groups, hospitals and health plans had grown dissatisfied with the processes by which its Claims Department was handling over 40,000 paper claims each month. They additionally desired to cut their claims processing costs.

Situation

This MSO was working with a local service bureau for scanning and converting their paper HCFA-1500s into EDI stream but was experiencing great concerns about timeliness, quality results and cost . While the client was incurring significant shipping costs to send their paper claims offsite, they suspected a certain percentage of their claims were being lost and not processed. Additionally, a growing percentage of converted data was inaccurate and causing claims to be improperly adjudicated.

While the claims data was returned from the service bureau 3-4 days later, the scanned images provided were not being indexed, and Adjudicators were spending unnecessary time searching for images. Additionally, the Service Bureau's limited capabilities required the MSO to host the images locally in their office. This presented a challenge as most of the adjudicators were working remotely and the MSO had to invest significantly to allow them access to view claims from offsite.

Finally, the service bureau was not equipped to process UB-92s and the MSO was forced to enter the UB-92s the old fashioned - by hand - utilizing their own staff.

Solution

Understanding the MSO's unique challenges and desires, MedValue responded with a custom solution based on our Paper Claims to EDI Utility Service. The solution enables the MSO to scan the claims in their mailroom, and instantly send them securely to MedValue, eliminating shipping costs. With the web-based MedValue Document Management System, the MSOs Claims adjudicators can instantly search for and view claims, making it easier and faster to adjudicate the claims from remote locations.

Additionally, MedValue responded with a solution that enables all HCFA-1500s and UB-92s to be reliably converted to the EDI format and securely transferred to the MSO each day for easy import into their Adjudication system, improving quality and turnaround times by 2-3 business days.

MedValue has also deployed the MedValue Workflow Management system. Now all claims are accurately tracked at the scanning station and monitored until the data is returned in EDI format back to the MSO. This ensures that claims are accounted for and not lost in the conversion process, and the MSO gains real-time status of all claims processed by MedValue.

Results

This MSO is highly satisfied with the transition to MedValue. They have realized 40% improvement in turnaround time, have reduced costs by 25% compared to working with their current vendor, and the data they receive is finally reliable for improved claims processing results.

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