www.mxocare.

com

Automating Claim Processing and Maximizing Medicare

CASE STUDY and Commercial Reimbursements

Background

There are millions of healthcare claims that require submission, processing

The large volume of data
and the need for extreme
accuracy in order to get
reimbursed, pose
challenges for the medical
providers.
and reimbursement on a daily basis. However, the large volume of data and
the need for extreme accuracy in order to get reimbursed, pose challenges
for the medical providers. As a means to promote quality Medicare claims
reporting, the government has established financial incentives and bonuses
to reward medical providers for positive outcomes.
A standard healthcare claim contains 250+ fields which must be correctly
completed to meet the contract requirements between the providers and
payers. The challenge was to provide a fast and reliable point-and-click tool
that can process the significant claim volumes for large numbers of medical
practices and ensure superior traceability and auditing capabilities while
shortening turnaround and correction times.

The Approach

MXOtech designed a web-based system that allows for the correction of

medical claims that have failed the processing requirements and have
therefore been rejected by the claims clearinghouse. The clearinghouse
transmits information to MXOtech’s Remedium application which identifies
the claims requiring correction. A number of data transformations take place
to further simplify the correction process for the end-user. One of the biggest
challenges that needed to be overcome was the fact that standard claims
Remedium gives groups contain over 250 fields that can potentially have errors. The old way of
identifying the errors consisted of the end-user reading through descriptions
immediate access to on the rejection analysis report and then trying to decipher what exactly
claims and limits the needed to be corrected. MXOtech’s new system, Remedium, gives a
complete makeover to the old approach with a new point-and-click interface
correction period to 10 that enables the users to ‘land’ directly on the fields that need attention. This
days. This increased allows for increased efficiency and much faster turnaround times when
efficiency yields much correcting and resubmitting claims, which in turn, leads to better
reimbursement. Remedium also traces and accounts for every single claim
faster turnaround times throughout the correction process – from claim rejection to resubmission to
and better reimbursement. the clearinghouse, which is done automatically as the system is able to
recognize when claims are ready for reprocessing.

The tool is designed to handle various business functionality needed for both
the medical providers and insurance payers by configuring the set of features
in a role based access.

MXOcare,
MXOcare, 1101
1101 W.
W. Adams,
Adams, Suite
Suite A,
A, Chicago
Chicago IL
IL 60607
60607The ©
© MXOcare
MXOcare
tool is designed to handle various business functionality All
All rights
needed forreserved.
rights reserved.
both
 www.mxocare.com

Automating Claim Processing and Maximizing Medicare

CASE STUDY
and Commercial Reimbursements

Results
The Remedium application offers a solution to a process that was overwhelmed
with challenges. The application plays a crucial role giving over 80 contracted
medical groups the ability to reconcile and re-process large volumes of claims
for over 9,500 providers which impact risk scores and reimbursements. Listed
Excellent tool to improve below are just some of its many benefits:
provider / payer
communication,  Improved turnaround times for error correction – from days to minute
relationship and customer  More rapid and consistent reimbursement pattern
service.  Simplified analysis of the claim rejection reports

 Dramatic improvement in traceability and auditing capabilities to

minimize lost claims

 Single point of access for multiple payer specific products – no new

links or user names and passwords to remember

 More accurate revenue forecasts due to shorter payment cycles

Data reconciliation for 80  Excellent tool to improve provider/payer communication, relationship
medical groups and 9,500 and customer service

unique physicians in the  A system that monitors claim progress and has the ability to provide real
time claim status and readiness for resubmission
network.
 Relief to provider and payer human resources of the tedious process of
claim correction by leveraging an easy to use and HIPAA compliant tool
Method

Projects were developed through the Agile Software Development Process,

with extensive creation of Use-Case scenarios.
Ability to provide real time
claim status and readiness
for resubmission. Technology

Centralized Portal: A SharePoint portal is utilized for management of single

point of entry and access to the application, document management and user
security access.

Application: Built on the MVC framework - one of the leading ASP.NET

programming models. It is a lightweight (compared to traditional ASP. NET
web forms) and highly testable framework. This approach ensured the best
performance and user experience for the web based application considering
the volume of claims data that flows through it.

MXOcare, 1101 W. Adams, Suite A, Chicago IL 60607 © MXOcare All rights reserved.