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Client

The client is headquartered in North Carolina and is one of the largest and oldest North Carolina based Medical Claims Clearinghouse firm. They currently contract for nearly 6,000,000 lives in the states of North and South Carolina processing millions of claims a month. They contract with Blue Cross and Blue Shield of North Carolina (BCBSNC), MedCost, Cigna Healthcare (South Carolina), Primary Physician Care, Carolina Summit and Kanawha.    Their customer base includes a large number of providers and managed care providers.

Background

Processing claims and receiving payments for services is critical to the healthcare industry. Electronic claims submission is beneficial to medical practices because it drastically reduces the turnaround time on accounts receivable. For many years claims were transmitted to insurance companies using paper forms (HCFA-1500) sent through the mail to be delivered and processed. However, this system is inefficient, costly and many insurance companies are pushing for healthcare providers to abandon paper claims and send claims in electronic format only. One of the primary benefits of the Health Information Portability and Accountability Act (HIPAA) was the creation of a standard data structure for electronically exchanged information within the industry.

Practice management billing systems utilizing these structures provide the greatest promise of reduced costs. Claims can be sent directly to insurance carriers using these structures; however, the primary delivery path for most claims is the use of clearing houses. Clearing houses are valuable to communicate between the practice and the insurance company, and an integrated system allows electronic data exchange between the practice, clearinghouse and insurance companies. Today many medical billing clearinghouses such as our client are still using partly automated, labor intensive and expensive processes.  

Business Requirements

The initial system requirements were based on Biz Technology Solutions staff input along with the clients input.  The objective was to develop an integrated web driven software system that would automate claim processing while increasing work reliability, efficiency and decrease operational cost.   In addition, it would permit our client Clearinghouse to compete more effectively with other emerging clearinghouses. A strategic business decision was made to design the system to allow our client Clearinghouse to support various medical practice types such as Chiropractic, Family Medicine, OBGYN, Orthopedic, and other practice types.  

Solution

Biz Technology Solutions, Inc provided a web based medical billing solution which caters to Medical Claim Processing “best practices” and HIPAA regulations. The application consists of multiple stages:


Front – end

The front end of the application is used by medical practitioners and their staff to submit medical claims. The application has separate logins for a doctor and his staff to enable different privileges to each according to their profile.

As input the system would accept various X12N electronic file formats such as HCFA 1500, CMS 1500, U92, ADA, 837 and other some non-standard formats.

On entering the application the user can key new claims online, upload claims that are generated by a practice management software (PMS), search previously submitted claims, view claim history, user statistics, and scrub claims that failed system validation.  A report feature allows viewing user audits, financial as well as accounting information such as daily insurance totals, balances etc. The user can also view and edit patient and practice profile, patient statements, Day sheets, super bills etc. A concise view on the login page gives a summary of various claims statistics like total claims, sent claims, paid claims etc.

Backend

The backend of the system performs Real-time claim error identification (L1, L2 and L3 validation) as well as a number of rule based edits defined by the payors and the client.  Additional rules are supported via profiles and user exits.   The system administrator can preview the claim total count of the daily submitted claims, daily insurance totals report, can configure Rule files for providers and payors, manage user credentials, create and send messages addressed to users and much more …

An enormous amount of data is managed efficiently by the system of all covered and non-covered entities such as Providers, Payors, Patients, procedure codes, modifiers, place of service, facility & labs etc. Finally an 837 Professional claim is generated in pure EDI format according to HIPAA rule and forwarded to the appropriate payor electronically and securely.

The system can set charges, commission on service as well as discounts for each provider associated with particular payors. This provides a full fledged billing and reporting facilities that supports provision to detect and submit result of 997 (functional acknowledgement), 835  (Remittance Advise) and other electronic data.  The system forwards payor claim batches of configurable size.

Technology Used

The system architecture is based on J2EE/SOA/MVC best practices resulting in a platform independent system that is highly maintainable, scalable, and reliable.

Conclusion    

Working hand in hand with our client using some of our existing products in conjunction with new software development resulted in an automated claim processing system that exceeded our customer’s expectations.  Our solution increased work reliability, efficiency while decreasing operational cost (reduced data entry work force by 60%) and increased revenue.  In addition, it positioned our client to compete very effectively with comparable businesses.