Hospital claims are funders single largest component of expenditure, and are therefore the single most viable target of cost management.
But hospital claims are clinically complex, financially intricate, and subject to complex rules and structures
that inter-relate in different ways. This makes manual processing of hospital claims time-consuming, very costly, and error-prone.
Manual claim adjudication therefore fails to achieve required savings for funders - even more so when offset against
member complaints and marketplace reputation.
HospiCheq, a proudly South African product, automates hospital claim adjudication, bringing efficiency, consistency, and cost-effective savings that rival those of intensive manual scrutiny.
HospiCheq also supports varying degrees of manual clinical audit so that funders can achieve a higher impact of cost saving where they have the scale to invest more in the clinical expertise overlay.
- Checks and adjudicates every single line item on a claim.
- Adjudicates claims according to rules for Clinical appropriateness.
- Paper claims can be converted to electronic and then adjudicated.
- 24 Hrs turnaround time on electronically switched Hospital claims.
- Accommodates various tariffs per funder option and Hospital Group.
- Able to Adjudicate Per Diems, Fixed Fees and Fee for Service accounts.
- Able to price both ethical medication and surgicals.
- Able to adjudicate multiple NAPPI tariffs
- Net Acquisition Price [NAP) and funder negotiated tariffs or list prices.
- Validate Drug and Consumables quantities for appropriateness.
- Does Duplicate check
- Does Member validation
- Applies funder rules
- Able to send Recon reports directly to the Hospitals making them aware of any mark downs or rejections.
- Queries are logged on the system
- Claims status tracking
- Full Audit trail of any changes to adjudicated value.
- Reports to funder on savings made.
- Authorisation Number
- Authorisation status (Granted, Cancelled, Pended or Denied)
- Same Patient as authorisation
- Same Hospital as authorisation
- Admission date
- Length of Stay
- Level of care
- Theatre time
- Authorisation value
- Prosthesis value
- HUM Co-payment (if required)
- CPT codes (Primary and secondary codes)
- CPT Code status (Granted, Denied)
- Diagnosis Codes (Primary and secondary codes)
To make it as simple and efficient as possible for the client to provide data, the data requirements are not prescriptive with regards to the file Structure. Files should preferably be pipe delimited with the data fields in the same order as requested.
Medsys would consider whatever format is easiest for the client to supply provided the required data is included and charge lines are not "repeated/duplicated".
Proof of Concept
As you can imagine, funders have different arrangements and rules which need to be integrated with Hospicheq. Let us prove value by undertaking a "Proof of Concept"
for your fund using your hospital claims' data - at a nominal fee