Auditing Claims Comprehensively

Improving the consistency of the application of their medical policies, payors using either solution typically save an average of 3% to 6% of total benefit dollars and more than 10% in administrative costs.

Further, ClaimCheck and CodeReview offer flexible customization capabilities, so payors can adjust the solutions' clinical knowledge bases to meet their own unique medical policy needs.

Delivering Wide-Ranging Benefits

• Pay claims more accurately
• Control administrative costs
• Apply consistent payment policies across physicians
• Enable prospective claims audits to educate physicians on how to code specific claims
• Decrease claims suspensions while increasing processor productivity
• Offer a variety of standard reports, detailing such information as coding problems or potential savings

Addressing Coding Issues

Drawing on the latest coding revisions and industry benchmarks, ClaimCheck and CodeReview address coding issues by performing several actions to

• Identify billed services that may have used incorrect codes and provide the reasons for denial, based on payors' medical policies
• Recommend fixes for incorrect procedure codes on physician claims
• Rebundle procedure codes to an existing comprehensive code on the claim or recommend the correct procedure code when one is missing
• Flag procedure submissions that require additional documentation or further investigation

Providing a Solid Clinical Foundation

ClaimCheck and CodeReview use comprehensive clinical databases that are developed and maintained by a team of full-time physicians, registered nurses, coding experts and other healthcare professionals. McKesson also has an extensive support network of more than 200 board-certified physicians covering many specialties and geographic areas.

The solutions incorporate multiple clinical coding sources, including:

• Current Procedural Terminology (CPT)
• Healthcare Common Procedure Coding System (HCPCS)
• International Classification of Diseases Clinical Modification (ICD-CM)
• American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) guidelines
• Specialty society guidelines
• Medical policy and literature research and standards
• Input from academic affiliations

Further, payors may obtain documentation regarding clinical logic through the McKesson client Web site Clinical Inquirer, a rich source of valuable information available 24 hours a day.

Creating Informative Reports

ClaimCheck and CodeReview offer flexible reporting capabilities so payors can:

• Document coding changes in physician reports to explain how each procedure was evaluated and the clinical rationale behind the decisions
• Detail costs associated with inaccurate billing and note the physicians involved
• Build custom reports
• Track the status of individual claims

Customizing ClaimCheck Specifically

To meet the needs of payors' contractual and medical policy differences, ClaimCheck offers the following:

• SmartSuspense™: This feature allows payors to easily configure tailor-made edits to audit by physician, specialty, member, procedure code, modifiers and other user-defined fields. Further, payors can set differing auditing results to flag, monitor or deny.
• MultiAccount: This feature allows payors to define and store multiple customization files. In addition, each account can have its own unique edits while sharing a single, core generic database.
• Onsite customization: Payors can customize both the software and databases in a variety of ways, with changes preserved from release to release without repeating data entry.

ClaimReview™

An add-on module to ClaimCheck, ClaimReview delivers a customizable second level of review for claims that usually require manual processing.

Medicare CodeReview^®

An add-on module to CodeReview, Medicare CodeReview helps payors align their policies with CMS guidelines.

ProMatch™

An add-on module to CodeReview, ProMatch increases payors' savings by identifying inaccurate and miscoded procedure/diagnosis combinations.