Clinical Compliance Tool For Providers

For more than 15 years, Context⁴ Healthcare Inc. has been serving healthcare professionals in speeding and perfecting claims processing for both providers and payors. ClaimsEditor^® includes the Windows-based Professional edition and a web application version. The product plays an instrumental role across the healthcare industry by utilizing the most advanced and comprehensive clinical editing technology available to ensure that claims are properly coded and are in accordance with applicable state Medicare, Medicaid, and other third-party payor rules and regulations. The unique editing, claims correction, reporting, and workflow management capabilities in the ClaimsEditor^® products deliver significant cost and compliance advantages for individual providers and provider organizations, and provide quantifiable benefits to all users within all segments of healthcare. Benefits include:

• Substantially lower administrative costs associated with managing physician claim volumes
• Improved regulatory compliance with government and payor guidelines
• Enhanced revenue and accelerated cash flow as a result of reduced payment delays
• Reduced audit risks
• Rapid return on investment

ClaimsEditor^® Professional

ClaimsEditor^® Professional is the most advanced and comprehensive clinical editing technology available to healthcare providers. It helps ensure that claims are properly coded and are in accordance with applicable state Medicare and other third-party payor rules and regulations. ClaimsEditor^® Professional examines the whole claim and identifies procedure-to-diagnosis mismatches, unbundling occurrences, use of nonspecific diagnosis codes, global service violations, potential unbilled revenue, and many other problem areas that can adversely affect not just claims processing, but a provider's overall practice.

ClaimsEditor^® Professional is a Windows-based system that makes it easy to integrate with most any claims processing system, and it can be deployed at various levels within the workflow. It is one of the most widely used and powerful solutions available, with more than 2,000 physicians currently enjoying multiyear licenses. One client is using ClaimsEditor^® Professional to process more than 100,000 claims every month. Its capabilities and functionalities include the following and more:

• Complete editing system: Built around the CodeLink^® software, the system provides users with access to all CPT^®, HCPCS, and ICD-9-CM codes along with coding rules, Medicare regulations, and fees, enabling users to better identify errors and make necessary changes-no other claims editing software has this ability.
• Real-time editing and batch editing: These functions keep claim flow moving with little or no interruption for existing users, and may also be installed as a data entry front end that allows users to identify and correct clinical coding oversights before data reaches practice management systems.
• "Clinical editing" as opposed to "technical editing": Edits are specific to the clinical coding aspect of the claim (for example, unbundling edits, ICD/CPT mismatches, global period violations, complete local coverage determination policies, correct coding initiatives, provider oversights, regulatory, reporting). Other solutions only edit technical aspects (for example, payor ID is 10 characters instead of the required 12).
• Rulewriter: Users, such as commercial payors, may create and write rule sets.
• Template creation and maintenance: Context⁴ builds and maintains state-specific Medicare templates based upon each Medicare carrier's requirements.
• Management reports: The system generates more than 20 management reports designed to help administrators better assess and manage claim generation and to better review the overall process, a valuable educational tool for physicians and coders.

ClaimsEditor^® Web Application

Like ClaimsEditor^® Professional, the ClaimsEditor^® Software as a Service (SaaS) version applies payor-specific clinical and technical edits prior to submission to third-party payors. Unlike ClaimsEditor^® Professional, the SaaS version delivers this functionality via an ASP application. Through a secure socket layer, the web application both delivers error notifications to providers and serves as a claim correction utility. It can notify the provider of any billing errors in two ways. First, it can generate an error notification document; second, it can generate an e-mail notification to the provider, alerting them to a claim error. In either scenario, the ClaimsEditor^® SaaS provides a secure web correction portal, allowing a provider to correct a claim online. In addition to the host of benefits delivered by its progenitor-lower administrative costs, improved regulatory compliance, reduced payment delays, and audit risks-ClaimsEditor^® SaaS also spares users an investment in hardware and has no integration costs. With healthcare spending drastically increasing each year, strict government regulations and reimbursement guidelines will only grow more complex. ClaimsEditor^® Professional and ClaimsEditor^® SaaS have proven to be, and will continue to be, invaluable resources for provider organizations struggling to stay compliant with rapidly changing rules and regulations.