Closed Loop Denial Prevention Process

To Prevent Denied Claims “When Rules are Used” is as Important as “What Rules are Used”

To Prevent Denied Claims “When Rules are Used” is as Important as “What Rules are Used”

AccelaSMART, the powerful processing and editing engine in the White Plume suite of products, is uniquely effective in ensuring that claims are paid not only because of what it does but also because of when it does it. Many editing tools apply editing technology to assembled encounters after they are already posted in the PM system.  One supervisor, an AccelaSMART user for over 10 years, says “I have an issue with using this type of tool [PM system editing tool].  Its [logic is applied] AFTER the charge has been placed in your system. That means, if any correction has to be done, it’s a messy process, reversing charges, recreating claims, trying to…communicate with a Coder/Office on how to fix the charge.”

By contrast, AccelaSMART evaluates encounters before they are transmitted to the PM system, informing the user of all potential problems that will produce payment denials. These problem areas can be corrected immediately and on the same screen.  AccelaSMART catches pure coding errors such as procedure-to-diagnosis mismatches, bundling/unbundling problems, E&M level upcoding/downcoding, and many other types of rule violations.  Further, it identifies general filing problems such as missing accident information where needed, and has a powerful rules manager that lets users create rules that are specific to their own payer mix and practice specifications.  One AccelaSMART user puts it this way: “Using AccelaSMART gives the ability to send communication back to the different areas and it’s done prior to posting to the system.  So much cleaner! Whether we used the EHR or are using coders [to generate the charges], there is nothing that can replace the ability to build edits at an insurance level, make sure all appropriate modifiers are applied, or rearrange diagnosis codes to corresponding tests!”

She adds:  “A good example of this is cataract surgeries.  Our Ophthalmologist does many of these surgeries, but many times does not do the post-op care. Our coders have continually forgotten to add a -54 modifier in this situation.  When missed, it creates a chain reaction of denials and rework when we file our post-op charge for partial follow-up care along with the Optometrist’s charge for the rest of the care. We want to look at these before they go out the door to confirm the modifier is there when needed.”

Many PM systems provide editing tools, but AccelaSMART’s superior coding engine provides the right rules at the right time to prevent denied claims before they happen so there is no mess to clean up!

Creating a Closed Loop Denial Prevention Process

What is a closed loop denial prevention process? payor-rule-changes-per-month
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