This healthcare organization was struggling to review the claims for its 80,000 patients using an outdated, manual process. By enhancing their claims process, St. Joseph’s Medical Resources realized considerable cost savings by catching erroneous claims.

Background

St. Joseph’s Medical Resources manages Independent Physician Associations (IPAs) and conducts billing and utilization management for physician practices. The organization was struggling with inefficiencies in its claims adjudication process because claims managers were not using any auditing software to review the claims for its more than 80,000 patients.

Situation

The organization knew that it needed to find the right software solution to move forward and increase profitability, but since reimbursement practices varied for each IPA that it managed, the claims department required a solution that would allow customization for highly technical claims. In addition, because many of their physicians differ in billing approaches, it was crucial that the organization used a consistent process in the way claims were reviewed, and payments were distributed.

Solution

After evaluating competitive options, St. Joseph’s installed PCG Software’s Virtual Examiner_® – a solution robust enough to handle even the most complex claims, while being flexible enough so that all claims team managers could access and change the system to their own needs and specifications. “You cannot rely on a manual system anymore. With Virtual Examiner_®, we have realized considerable savings as a result of catching erroneous claims that may have otherwise been missed during the manual process.” — Renya Jackson, claims team manager Every evening, Virtual Examiner_® automatically adjudicates claims for each line or business. Then, claims managers can access the claims server and run denials or explanation of benefit reports – sorted by batch and examiner ID. The claims team managers then use these printed reports to review and adjust any questionable claims.