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Case Studies - Monarch Data Pump 7

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Aesthetic Enhancement Center (AEC), a two-physician plastic surgery practice locat­ed at Beverly Hospital, in Beverly, Massachusetts.


Reclaiming the Healthcare Claims Process with Monarch Data Pump

"With Monarch Data Pump, we expect to reduce AEC's claim write-offs due from automatic denials by 95%! 
 This also frees up AEC's office
managers to devote time to dispute other claims that are denied
for more substantive reasons, such as a dispute over the submitted procedure code."

"We then suggest giving serious consideration of Monarch Data Pump
an easily implemented solution to help automate and greatly improve the insurance claim submission
collection process."

  • As the old joke goes: "My doctor gave me six months to live, but when I couldn't pay the bill, he gave me six months more!" If only health insurers were so flexible. Healthcare providers today must meet stringent filing demands for an insurance claim to be even considered by the insurer.

  • A key piece of any healthcare organization's claim processing strategy should include automation of the handling of errors during the claims process. Monarch Data Pump Server Edition has met this important need with great success, says Rahul Patel, senior consultant for Synapsys, a Massachusetts-based healthcare consulting firm. Synapsys recently implemented Monarch Data Pump Server Edition for Aesthetic Enhancement Center (AEC), a two-physician plastic surgery practice located at Beverly Hospital, in Beverly, Massachusetts.

  • "Many healthcare practices submit insurance claims electronically to a claims pro­cessing clearinghouse," explains Patel. "AEC uses McKesson as its claims clearinghouse.  McKesson validates that each claim is in the right format, and can even correct minor errors on the claims submitted. The claims are then transmitted via EDI to each respective insurance provider.

  • "It is possible, however, that the claim may still contain errors not picked up by McKesson.  Perhaps the patient's date of birth is incorrect, or the patient's insurance ID has a few numbers transposed.  Such claim submissions are, for one reason or another, not 'clean' and are returned by the insurer back to the clearinghouse as a rejected claim. This rejection process can take as much as 30 days. Meanwhile, other claims are accepted as 'clean' claims and go into the insurance company's adjudication system for payment.
  • The status of each claim is reported back to McKesson, which in turn generates a text-based rejection report," Patel continues.  "Monarch Data Pump Server Edition is used to automatically open these claim documents and identify those claims which have been returned due to errors.  Relevant data such as the patient name, ID, date of service, error codes, etc. are mined from those particular claim documents. Also, we have set up Data Pump to do an automatic lookup to an error code database, to include not only the error code number, but a text description of that error.

  • "The end result is a single report, created using Monarch Data Pump, listing all claims returned due to errors and all rele­vant details.  Previously, the office staff had to manually open the rejection reports, and visually scan it just to find those claims rejected and pending due to errors. Monarch Data Pump eliminated what was easily a daily 45-minute exercise sifting through each and every claims document! Monarch Data Pump gives AEC back sub­stantial administrative time each week, which is used to do a better job of challenging claims that have been denied for other reasons.

  • "Every dollar earned from a successfully challenged claim goes straight to the prac­tice's bottom line profit," adds Patel.  "Plus, when it comes to healthcare claims, time is of the essence, literally.  For all insurers, if a valid claim is not resubmitted within a set period after the date of service, the claim is automatically denied without further recourse. Monarch Data Pump helps elimi­nate such needlessly lost revenue, by help­ing to reduce the time necessary to reprocess a rejected claim. With Monarch Data Pump, we expect to reduce AEC's claim write-offs due from automatic denials by 95%! This also frees up AEC's office managers to devote time to dispute other claims that are denied for more substantive reasons, such as a dispute over the submitted procedure code."

  • Patel recommends healthcare organizations take a hard look at how much claims a healthcare organization is writing off on an annual basis due to automatic denials -erroneous claims not corrected before the insurer's deadline.  Another important con­sideration is how much office time is being spent on fire drills to hastily find and resubmit erroneous claims near the dead­line.  "This wasted administrative time reduces the remaining available time to contest other denied claims for other reasons," says Patel. 

© 2004 Datawatch Corporation. Monarch and Monarch Data Pump are trademarks of Datawatch Corporation. All other trademarks are properties their respective owners.



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