Healthcare Payer Case Studies

Claims Management - Process Innovation and Technology Resulting in Cost Reductions

The Challenge: Prohibitive labor cost and considerably higher turnaround time due to large number of manual adjudications resulting from mismatched information between enrollment data and provider data.

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Provider Data Management - Process Innovation and Technology Result in Cost Savings

The Challenge: A cost intensive update process that required checking all data on provider information update form rather than ones which were changed (typically only 40%).

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Risk Score Optimization through CDI

Scope: A major university-based health system wanted a thorough review of their documentation to see if it was supporting the level of care they are providing to the risk adjusted patient population. Clinical documentation review is a vital process for any patient encounter because this facilitates accurate representation of a patient’s clinical status that translates into capturing the ICD-10 codes to the highest specificity.

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