Patient Responsibility & Payer Pre-Billing Requirement Impacting Your Bottom Line? Engage Physicians and Patients with Patient Access Solutions & Analytics To Improve Revenue
Quadax Benefactor Session Tuesday, April 30 8:30AM – 9:20AM
CLAIMS MANAGEMENT
Market Trends & Challenges
9 in 10
7 in 10
Healthcare consumers would like pricing
information in advance of care
Patients are more likely to use a provider or service
that estimates out-of-pocket expenses upfront
Highdeductiblehealthplanscontinuetorise–in2019expectedtobeover60%oftotalemployeeplans
• Steadyincreaseinpriorauthorizationandmedicalnecessityrequirementsforcomplextesting
• Traditionallyaverymanualanddisconnectedprocess
• Clinicalrequirementschangeoften,requiringasignificantamountoftrainingandeducationforprovidersandstaff
3:5,000perday(100,000permonth)
AverageAllowable:$650pertest
• PhysicianOrderingportalbuiltonSalesForce• Withoutintegration,manualPatientAccessprocesswas
timeconsumingandstillresultedinhighnumberofencountersabandonedasself-pay
• Evenwithmanualprocesses,35%oftheiraccessionshadmissingorinvalidpatient/insuranceinformation
• Increasingnumberofdenialsduetomissingpriorauthorization/statementofmedicalnecessity
Rejected–Badinfo
65% 35%
CleanEligibility
Aninefficientprocesswithsignificantback-and-forthwithpatientanddoctor.
Highnumberofabandonedencountersincorrectlyconvertedtoself-pay
Patient Physician OrderingPortal LIS PatientAccess&Billing
https://www.beckershospitalreview.com/healthcare-information-technology/the-api-revolution-in-healthcare-s-evolution.html
•
•
Healthcare service provider application/s
APIs connect processes, services, content, and data
AdvancedEligibility
You Us
API
UI
Hybrid
Patient Physician OrderingPortal LIS PatientAccess&Billing
Servicesintegratedatpointofdecision(flexibility:patient,physician,LIS)
17 ©2018Quadax,Inc.
EligibilityandcoverageatorderentryPatient’sinsurancefromorderentryisusedtocreateareal-timeeligibilityresponseviaAPI.Presentseligibilityanderrorstoaportaluserearly–beforeorderisevencompleted.
18 ©2018Quadax,Inc.
InsuranceDiscovery
Whendataorcoveragewasunknownorinvalid,insurancediscoveryfoundcoverage,inreal-time–beforeanorderwasevencompleted.Insurancediscoveryreducesnumberofclaimsrejectedformissing/badeligibility–from35%to21%.
inself-payanduncompensatedaccounts
40%reduction
CleanEligibility
65% 35%
Rejected–Badinfo
CleanEligibility
83% 21%
Rejected/BadInfo
Before:
After:
19©2018Quadax,Inc.
Auto-PlanSelectionandPriorAuthorization
1. SpecificInsuranceautoassigned
2. LookupAssociatedPre-Claimclinicalrequirements,e.g.priorauthormedicalnecessity
3. Helpsdriveworkflowanddenialavoidance
Rejected–Badinfo
usingpriorauthtostayinformedofpayerclinicalprograms
26%Fasterpayment
Billing ID 127
Payer Aetna
Plan PPO Choice Plus
Pre-Claim Requirements
Prior Authorization Required Statement of Medical Necessity
PatientOut-of-PocketEstimation
• Benefitsderivedfromeligibility
• Costderivedfromexpectedamountsoraverageallowablebypayer/plancontract
inadditionalreimbursementsper
monthduetoinsurancediscovery
inadditionalreimbursementsduetodenialavoidance
divertedtohighervaluetasksdueto
operationalsavings
4%(decreaseinauth/mednecdenials)x100,000testsx$650averagereimbursable
14%(decreaseinbadinfodenials)x100,000testsx$650averagereimbursable
thisisbasedonassumptionthatroughlyonly20%ofbadinfoaccountswerehandledbyteam
Thank you.
