Goal
- Enhance revenue growth, drive administrative efficiency, improve cost and quality of care, and improve the member and patient experience.
- Revenue cycle management in healthcare is essential for the healthcare practice to maintain financial viability and to provide quality care
Solution
- Apply business rules and harmonize data for medical, hospital, and pharmacy claims
- Dashboards and Reports for Member eligibility, High cost claimants, Finance paid summary, Monthly claims summary, Claims by Cost Utilization group and Top 10 Procedure and diagnosis codes
- Process data from Claims, enrollments, and pharmacies
- Monitor financial metrics, utilization, and quality
- Member Eligibility coverage rules vs options
- Pharmacy claims summary and detail by drug and claims paid
- Insights into likelihood of claim denials based on human actions throughout revenue cycle management in healthcare.
Results
- Identify and improve gaps in existing systems used in revenue cycle management.
- Reduce time consuming workflows in Claims submissions.
- Allows Administrators to identify actionable areas for improvement.
- Helps control the costs of High Utilizers by providing proactive reports with cohorts and diagnosis and procedure codes.
- Optimize Care Management by better targeting resources and estimating potential savings at the plan, ACO and employer level
