Coding, Billing, Claims processing

Coding Automated Claims Processing EDI submission and remittance Reimbursement Maximization (3M) Authorizations/case Management Payment Posting

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Automated coding

iMedica PRM's automated coding improves coding accuracy, eliminates the need for manual charge entry, and increases reimbursements. At the end of each visit, the physician is presented with an E&M coding summary, detailing the diagnosis, procedure(s), accumulated points and visit level earned. When the physician either accepts the recommendation or changes it, then closes the chart, iMedica PRM immediately creates a superbill and routes it to check-out.

• Correct diagnosis and procedure codes are automatically selected based on the clinical record and the patient's insurer requirements and fee schedule, instantly creating accurate bills for both insurers and patients
• Appropriate visit level, based on the documentation during the visit, is displayed for physician approval, preventing undercoding
• All services and procedures are billed, eliminating dropped or forgotten charges.
• Built-in error checking and reimbursement maximization with the 3M™ Edit Engine reduce errors, speed reimbursement, and reduce staff time preparing resubmissions and appeals

Automated claims processing

iMedica PRM manages complex insurer fee schedules, primary and secondary insurance, and even self-insurance in real time, speeding claims and accurate patient statements.

The iMedica claims workflow has just three steps: Review superbills; review claims; and balance and close, which sends claims to EDI (electronic data interchange). Reimbursement rules, ABN, PQRI, and the 3M Edit Engine "code scrubber" are all built in, practically eliminating errors. "Balance and close" itself is so fast that experienced billers find it hard to believe-just one click accomplishes those tasks instantly. Everything in the claim has already been checked during the patient check-in, visit, check-out, and superbill review; there's no need to do it again.

• Insurer fee schedules:
  • Unlimited number of insurers and fee schedules with auto-write-off; date ranges can be set to allow pre-coding of new rates.
  • Integration with charge capture and code validation ensures complete, correct billing the first time.
  • Integration with demographics auto-adjusts for primary and secondary coverage in real time, at the time of charge entry, so that it doesn't artificially inflate A/R.
  • Ability to create multiple plans under one carrier (Aetna PPO, Aetna HMO, etc.) makes it easier to set up new payers and post payments/EOB
• Practice-specific payer database stores form, ID format, reimbursement rules, drug formulary, and a "claim scrub profile" for each payer, eliminating the need to repeatedly look that information up or reformat claims.
• Built-in PQRI (Performance Quality Recordkeeping Initiative) rules ensure that all the necessary documentation has been submitted for the practice to be eligible for the 1.5% CMS (Medicare) bonus. Error-checking routines and the 3M "code scrubber" identify potential errors to reduce rejected claims.
• Total, accurate, adjusted patient balances (including adjustments, co-pays, and co-insurance) shown at patient check-out
• Tracks annual allowable amounts for each patient and insurer, including how to allocate insurer and patient costs; allowed amount schedules auto-update from payment entry
• Financial data is managed in batches for familiarity and convenience

Electronic claims submission and remittance

iMedica has simplified EDI to ensure that practices can submit claims and be paid quickly. Immediately after implementation, iMedica trainers provide extra help to support the practice's cash flow during the transition.

• Electronic claims submission and remittances reduce accounts-receivable times from 60 days to, usually, less 10 days
• Electronic remittances are automatically applied to the correct patient, visit, and insurer
• EDI is tied to the iMedica Messaging Center and tasking functions, making it easy to assign tasks or fix problems when they arise
• All iMedica EDI transactions are HIPAA compliant
• iMedica PRM supports multiple clearinghouses to offer more choice, flexibility, and cost-effectiveness

Reimbursement maximization (3M™ Edit Engine)

iMedica PRM integrates the 3M Edit Engine, which provides immediate, constantly updated code validation and reimbursement maximization. The iMedica system simultaneously looks for other EDI and claim errors, saving both steps and time. The 3M Edit Engine is online, providing real-time accuracy and eliminating manual updates. The system works for any or all payers, using either national or local rules.

To use code validation, the biller simply clicks on the icon from the superbill list or an individual claim; iMedica compares the codes in all of them with more than 200,000 current CMS rules, both national and state/local rules (LCD). iMedica PRM then displays a work list of all errors to be reviewed, then fixed or accepted. The biller then clicks update, which updates the entire account. At any step in the process, the user can drill down into any item or area of the iMedica system to check information or make a correction.

• Compares superbill codes with more than 200,000 current CMS rules (both national and state/local), all built in and updated in real time over the Internet, to reduce claim resubmissions, denials, and appeals
• Enables pre-service reviews to confirm Medical Necessity and ensure that Medicare will pay claims or notify patients of their financial responsibility
• Runs in real time with a single click, without requiring a separate program, upgrade, or patch
• Allows flexibility to set which payers use which rule set, local or national, or any code validation at all.
• Clicking on an error alert brings up a message listing the potential error (for example, "CPT not compatible with patient age"), the level of error, and usually a hyperlink to the CMS description explaining the proper use of that code
• Creates a permanent, searchable record of errors and corrections
• Allows billers reworking old claims to return to rules in effect at the time of an old visit

iMedica PRM also includes built-in PQRI rules; see more details under "Reporting."

Insurance authorizations/Case management

To make payer authorizations more manageable, iMedica PRM includes powerful Case Management tools linked to its messaging and task management capabilities. iMedica solves the problem of marrying a purely clinical case to the needs of a financial case by allowing the clinical case to contain multiple authorizations and span any length of time. Patients with chronic conditions may have numerous procedures and several different payers; in iMedica PRM, one "patient case" manages the full history of authorizations in one place.

Authorization Messages, which can be created from the desktop, the main clinical screen, or from case management, are pre-populated with the appropriate codes and routed to the person who obtains authorizations. One request can be a single procedure or a set of procedures. The Patient Case screen includes all the information needed to call a payer for authorization, and completing the screen automatically updates the case. Once approved, the message is re-routed back the provider with authorization to proceed.

iMedica PRM case management simplifies authorizations in many different ways:

• Because one Patient Case spans multiple authorizations and procedures, it provides a history of authorizations spanning as many years as necessary.
• Case management is part of iMedica's task management functionality, which makes it easy to assign requests; track pending, completed, and historical authorizations; and inform the provider when authorization has been approved or denied
• iMedica doesn't require users to create a case just to put an authorization number in a visit.
• If a patient case exists, iMedica PRM grays those fields in the visit and pulls the correct information from the case

Payment posting

iMedica PRM was designed to simplify posting even the most complicated payments, even secondary insurance and multiple plans on one EOB (Explanation of Benefits form). Payments are entered, then distributed to visits or claims-and posting does not have to be finished the same day it was started.

The patient ledger provides a convenient summary with the description, payer, reference number, adjustments, payments, etc. Detail is provided on any open item; once it has been paid, the item drops off.

Some benefits of iMedica payment posting:

• iMedica easily manages multiple plans, secondary insurance, adjustments, and more from one screen
• Secondary insurance is auto-calculated and already queued in the patient ledger; nothing needs to be entered
• iMedica allows unlimited adjustments to any line item (insurance adjustment, discount, deductible, etc.).
• Personal payments can either be allocated to a particular line item or to the oldest or newest balance
• Status notes can be added directly from payment entry