Medical Claims Administration
At NGS CoreSource, we see a real difference between mere claims processing and effective group health plan administration. In our view, claims processing is relegated to a mere transactional function by some payers, while the kind of administration we provide requires high level expertise, patient centric processes, and attention to customer service. Claims administration is our core business - so your claims will be paid accurately and timely. Other highlights include:
A trained staff, dedication to customer services, and your hands-on control - these are the differences between merely processing claims and the kind of claims administration NGS CoreSource provides.
- Our claim system is completely flexible, so it does not dictate or limit your plan design options. Because our system has been developed internally, we can modify it to meet any client's needs.
- Trained benefit analysts handle all aspects of customer service related to claims, including answering your questions or questions from your employees. This means most inquiries have a resolution on the first call.
- We try to eliminate the assembly-line atmosphere, so common to other claim processing operations, by assigning analysts to work in small teams specifically dedicated to your plan. Quality is monitored constantly through regular claim audits and daily productivity reports.
- Fiduciary-level appeal services are available on an optional basis. In order to ensure quality and objectivity, all claim appeals are handled by a separate department that specializes in appeals.
- Detailed claim information is available for employers and employees via the NGS Self Service InfoCenter (employees) and NGS HR Self Service site (employers). NGS' dynamic website allows secure, Internet access to many great features including paid, pended and open claim data, total accumulations, online Explanation of Benefits, ID card requests, the ability to respond to correspondence (such as COB requests) and optional consumer health information tools. These tools can be utilized to track each claim from the date it is received in our mail room until the date we issue a check or explanation of benefits.
- NGS CoreSource devotes special resources to specialty claims that are either high dollar or high intensity due to another reason - such as chronic illness. The Complex Claims Unit analysts work with claims that require a higher level of clinical expertise particularly areas of outpatient therapies such as dialysis, chemotherapy, pain management and speech and physical therapy. Additionally, this unit is responsible for "predeterminations" - the process by which a provider or plan participant request benefits information in advance of services being rendered. This facilitates early identification of candidates for case management even when an inpatient stay is not involved.
Fraud and Abuse Protection
NGS utilizes fraud and abuse software to assist during the adjudication process.
An expert rule system is provided by ClaimsGuard under our partnership with TC3, specialists in claim risk management software. ClaimsGuard differs from other code review systems in a number of ways including the ability to examine the data on a claim within the context of the "big picture" of all claims data on that patient and that provider. Because ClaimsGuard is examining a volume of historical data, not just a snapshot of the current data, and includes a provider variance tool, it is able to identify certain upcoming and duplicate situations that are missed by standard code review products. Additionally, ClaimsGuard goes beyond standard clinical practice guidelines from the AMA's Physicians' Current Procedural Terminology (CPTTM) publication, and also brings CMS' CCI edits and as well as proprietary edits based on widely accepted textbooks of medicine and surgery, expert consensus from positions papers published by specialty societies, and published studies in medical research literature (e.g. RAND Corporation's published data regarding episodes of illness and diagnosis groups in its Health Insurance Experiment). Analytics include procedure repetition, high dollars per day, high paid procedures, missing modifiers, unusual procedure rate and unusual timed procedures.
Predictive analytics are provided by Fair Isaac under our partnership with TC3. A neural network is a type of predictive model that is particularly good at recognizing subtle, hidden and newly emerging patterns within complex data. They have become the standard for combating fraud in the credit card industry and they are playing an increasingly important role in today's stepped up international efforts to prevent money laundering. Fair Issac is a leader in the commercial application of neural networks with partnerships with 99 of the top 100 banks in the nations and 65% of all credit card transactions.
Another way neural network models are sometimes likened to the brain is in their capacity to "learn". In fact, the more a neural network model is used, the more powerful it becomes because neural networks usually analyze current transaction data along with profiles (equations that express significant historical data relationships). With each analysis, new transactional data and analytic results are fed back into the profiles, making them descriptively richer and more accurate. The next time the neural network model uses the profile, it is working with better data and therefore able to make better predictions. Using this technology in health care is increasingly important as systems that rely on rules alone can recognize only known behavior patterns (you can't write a rule for something you know nothing about), while systems that employ neural networks can also detect new and emerging behavioral patterns. Fraud perpetrators are creative and resourceful, continually modifying their schemes to escape detection. Because neural networks can recognize typical behavior, they can also recognize anything that departs from it, enabling them to quickly spot patterns never before seen.
Additionally, NGS utilizes unbundling software to identify questionable billing practices. The software is provided by McKesson who holds the largest share of the market. The system compares procedures with the American Medical Association's coding standards, flags anomalies and suggests more appropriate coding options. Its edits include areas such as:
- Unbundled procedures
- Automatic rebundling
- Incidental procedures
- Unlikely code combinations
- Inappropriate primary ICD-9 for procedure code
- Maximum daily frequency
- Valid CPT modifiers
- Potentially cosmetic procedures
- Elective procedures
- Investigational/Experimental procedures
- Surgical assistant procedures
- Invalid place of service