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The purpose of claim adjudication and audit is to root out any processes that may have violated stipulations
in the contracts between payers and payees. Although claim processors are trained to understand complicated rules and expected to execute them
correctly, these rules vary by the insurer and health care provider. On top of that, they are far from permanent or predictable, as they are constantly
modified.
Smart Edit Rule is a rule-based database solution that is designed to find heath
care claims with financial defects and to stop overpayments. Smart Edit Rule (SER), a subsystem of Smart Audit Master (SAM), has been designed,
developed, tested, and enhanced for over a decade by Phoenix Business Computing. Both SAM and SER have successfully met the serious challenges
from the largest medical insurance companies.
Unprecedented
Historically,
most major medical insurance companies in the US have been unable to apply the same methods used by Smart Edit Rule to identify claim defects. The SER
solution is unique and non-invasive. Phoenix Business Computing understands that every claim payment system works differently and has its own patterns
of defects, be they financial or procedural. The SER solution does not interfere with a client’s complicated claim-adjudication processes.
Preventing and removing defects is both costly and inefficient. The current method of identifying and removing defects requires a great deal of human
intervention. Unfortunately, the results of the intervention are neither consistent nor guaranteed; often defects are noted, but are unable to be
resolved. SER addresses these issues, conserving company financial and employee resources.
Independent
The Smart Edit Rule application is a subsystem of Smart Audit Master. SAM also
has claim audit and rebuttal subsystems; clients can pick and choose which subsystems to install. All run on Microsoft Windows 2003 with Microsoft SQL
Server 2000/2005. Clients can set up a single server or several servers depending on claim volume and the size of their user community. The application receives claim data and other related data from the claim
payment system in user-defined intervals. Raw claim data is input directly to Smart Edit Rule and defect claim lists are generated as output. SER uses
powerful edit rule logic technology, based on an edit rule engine.
Non-intrusive
SER offers the client total flexibility as there is no need to tie SER
processes to a client’s claim payment system. SER does not change any data; the application processes within the claim payment system. SER generates
defect claim lists as separate text files. The claim payment system may or may not use the list based upon the client’s needs.
Dynamic
SER’s flexibility also means that businesses can revise and edit rule logic on a daily basis. Clients can add or remove conditions and
parameters and change the order of rule execution. This allows businesses to steadily reduce false-positive rates, quickly achieving zero false
positives by examining the results of the current edit rule and updating the system logic. This flexibility and easy updating assures clients do not
waste precious time checking clean claims.
Accurate
Edit rule logics are a series of logical expressions of relational database
queries. They mix logical, mathematical, relational operators as well as comparisons and references together to extract and indentify claim defects. Once a client has created and confirmed each edit rule, the rule runs
identically every the time with no user intervention.
Fast
SER is unprecedented, independent, non-intrusive, dynamic, and accurate. However,
these attributes are useless if SAM cannot return defect claims to businesses quickly enough for them to take action to prevent financial
losses. Each day, one million claims are sent to SAM for processing as early as 4 AM. By 6am, businesses can starts
reviewing defect claims. SAM can run approximately 500 daily edit rules before noon and return roughly 7,000 potential defects to edit rule
examiners. The examiners can stop checks immediately, even before the payments go out to doctors and hospitals. Additional data analysis and web
reports are delivered within days, not weeks or months.
Detailed
Edit rules can be built in many different forms and throughout multiple layers.
To find duplicate claims, SER edit rule logic compares data and value in the claim line level, in between claim lines within a claim, with aggregated
value in the claim level, and between individual claims. Edit rules have two modes: One mode employs daily edit rules running against the claims
sent to SAM; the second mode runs past edit rules against the data set for today’s claims and also searches through previous data sets for a
user-defined duration (such as 30 days, 180 days, or a full year).
Flexible
Edit rules can be classified and configured to send defect claims to the right
group of examiners based on those classifications. These classifications can be by fund source, claim type, the level of paid amount, responsible
claim office, project, processor, policy or account, or special interest group. Additionally, each edit rule and defect claim can be assigned a
control number, allowing only pre-assigned examiners with proper credentials the ability to review them.
Reliable
The edit rule builders at Phoenix Business Computing have worked with leading
medical insurance companies for a decade. They are highly efficient at converting complicated defect scenarios into edit rules, usually within one
day. Once created, edit rules can be employed immediately and defect claims can be stopped that day. Millions of dollars of overpayments are detected
every week; overpaid claims can be adjusted or repaid. This type of efficiency sets Phoenix Business Computer apart and saves clients both time and money.
Proven
The methodologies and technologies of the Smart Edit Rule solution, coupled with the quality service and support from Phoenix Business Computing have been accepted and proven by largest healthcare insurance companies in the United States.
For over five years, United Healthcare has relied exclusively on the Smart Edit Rule solution by passing the entirety of its daily claim adjudication
results through thousands of edit rules specifically designed and built for their unique claim payment practices.
Responsible
Business partners love our services and our people. Phoenix Business Computing continually meets and exceeds the demands and challenges of large corporations and has earned its strong reputation in the healthcare insurance industry.
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