5201 Blue Lagoon Dr
Miami, FL 33126
(305) 262-1292
5201 Blue Lagoon Dr
Miami, FL 33126
(305) 262-1292
Independent Living Systems (ILS) is a health-services company that develops, delivers and manages community-based services and nutritional support for millions of America’s Medicaid, Medicare, dual eligible, and Special Needs populations – including the blind, developmentally disabled, and children – through financial re-alignment programs such as: •Dual eligible demonstrations •Managed long-term services and support •Managed Medicaid •Special needs plans (SNPs) •Developmentally disabled •Accountable care organizations (ACOs) In partnership with health plans; providers; hospitals; and pharmaceutical and medical device companies, ILS provides managed long-term support services aimed at improving health outcomes while rebalancing costs. The Company’s integrated offering, powered by eCare Central, ILS’ award winning technology platform, provides assistance beyond the clinical realm at every stage of care – from acute hospitalization through experiences with chronic illness, to personalized care management for the long term including nutritional support.
A claims scrubber module represents the most vital cost containment tool for payers and TPAs in adjudicating claims from healthcare providers and for IPA and MSO analyzing claims paid by HMOs. Millions of dollars can be saved! Also a claims scrubber with pricing capabilities can simplify the job of Case Managers estimating claims of services rendered by providers that are considered “out-of-network” Our HPP AccuChecker team has developed seven (7) claims scrubbers systems in the last fifteen years – we learned that you can develop a claims scrubber in 60 to 90 days if you have a team of programmers and healthcare reimbursement experts working together. It is understood that an adequate training session and a good map of the adjudication rules will guarantee the success of the in-house scrubber. A good in-house claims scrubber must: •Adhere to CMS and AMA adjudication guidelines in paying claims •Verify members participation in the insurance plan •Validate dates, places of service, procedures, modifiers, units, pricing, diagnosis (ICD-9-CM and ICD-10-CM) codes and co-payments •Adjust duplicate lines in claims •Keep an eye on UPCODING and the relationship between E & M procedures and places of service •Reject double billing when global fees and modifier 26 are charged simultaneously for the same day of service – common in hospital radiology services •Check medical necessity by matching procedures and diagnoses •Identify and react to UNBUNDLING by using up-to-date CCI tables •Track payment of bilateral and multiple procedures including endoscopy services •Follow basic rules on claims using numeric and alphanumeric modifiers for anesthesia, surgical, medical, diagnostic and rehabilitative services as well as supplies, DME and orthotics •On inpatient admissions observe that there is only one admitting physician and that double charges for surgeons, ER and admission are flagged •In the case of Medicare and Medicaid HMOs stay in constant watch on the two major areas of waste and mismanagement by some of the Plans – Pharmacy and Behavioral Services •A more advance analyzer will take care of HEDIS and PQRS measures – Alerting by patients in file the measures required by member during the year and the status of measures pending for each participant during the pertinent filing period. FOR MORE INFORMATION ABOUT CLAIMS ADJUDICATIONS SEMINARS & CONSULTING SERVICES: Please contact us at (305) 227-2383 Email: [email protected]
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