PAYERs / TPAs / MAOs SERVICES

“Cost-effective and Reliable Claims Administration Services for Health Insurance companies.”

A surge in healthcare enrollment has occurred due to the Affordable Care Act. This has caused an increase in both high-risk consumers and an aging healthcare population. As a result, payers must process more claims than ever before. By aligning payers and service providers, Augustus HCS helps ensure smoother claims processing and a reduction in overall operating costs.

In an evolving and ever-changing healthcare industry, Augustus HCS provides payers with more strategic choices for greater competitiveness. Augustus HCS helps insurers meet the demand for special skills, increase speed to market for extended offerings, and trim administrative costs. Augustus HCS also helps raise accuracy in adjudicating claims and the exchange of information throughout your organization. Augustus HCS offers services in configuration, front-end, claims administration and adjudication, enrollment and billing. With easy adaptable delivery models, payers use Augustus HCS’s value add services either continuously or on demand by working with onsite and/or offshore professionals.

Many of our clients have achieved cost reductions of as much as 30 percent in process related services and 10 percent in overall administrative services.

Workmen Compensation & Auto Insurance Medical Bill Review Complex Medical Review & Claim Repricing Claims Management & TPA services CMS-1500/UB-04 Electronic Form Conversion Data Entry HCC Coding/Medicare Advantage Organization (MAO) Services

Augustus HCS has found that providers treating job related and/or auto injuries bill the payers beyond the limits set by state Workers Compensation Board (WCB)/ Standard fee schedules, typically by presuming or anticipating delayed payments.

Redundant claims have also been found and are not uncommon, which adds to additional expenditures of medical dollars.

Augustus HCS’ work on behalf of Third-party administrator (TPA) assures providers receive prompt payments and get repricing done through professional negotiations.

By establishing a basis for repricing, our negotiations ensure prompt and earlier payments by encouraging providers to stick to mandated state fee schedules. We assist in applying for further discounting if providers are empaneled net-work providers. We also avoid redundant claims through our smart auto adjudication software to heighten profitability.

In these Worker’s Compensation and Auto Injury cases we work on a contingency basis. We base our fees on the savings achieved by payers after Augustus HCS implements repricing and negotiation initiatives.

This is a value add service we offer to TPAs/Payers beyond the normal performance limits of auto-adjudication software. Pricing efficiency is achieved post billing by applying network discounts and repricing initiatives.

The medical necessity of some services is found in many instances to be questionable. These questionable issues cause payers large sums of money and the instances of abuse is sky rocketing. When a mismatch between clinical documentation and coding (ICD-10/CPT-4 and HCPCS-II coding) becomes the basis of our repricing and negotiations. We also work with providers to reduce unbundling and over coding issues. Augustus HCS has found that high value services such as 4th or 5th level evaluation and management (E/M) codes, surgical services performed in the operating room have missing support components, such as duration of services. We challenge these undocumented services with the help of our medically qualified clinical staff deployed within Augustus HCS.

Our clinical staff apprises the clinical documentation based on evidence driven medical procedures by applying tools such as InterQual criteria, and the Milliman Care Guidelines (now known as MCG) for an appropriate utilization review.

  • Processing of the provider’s claims for determining appropriate amount to be paid against the claim is an important aspect of Claim Adjudication.
  • We help TPAs/ Payers to process the claims by using automated software as well we conduct Complex Medical Reviews to determine the Medical Necessity for Utilization Reviews of the claims.
  • Our team of expert Coders/Auditors keep constant eye on changing rules of payers as regards to eligibility, allowable amounts, exclusions and riders and keep our BRD (Business Rules Development) engines up-to-date to ensure maximum cost savings in expenditure of Claim Settlements.
  • We also help payers and TPAs for consolidating claims and claims data for appropriate indexing/sequencing for faster adjudication process.
  • We also offer Credentialing and empaneling services for successful enrollment of providers with the plan.
  • Complex Medical Reviews include- assessing coding compliance, provider documentation, and reimbursement audits.
  • Additionally, we provide program development and audit assistance to entities and subcontractors working with Medicare Administrative Contractors (MAC), Recovery Audit Contractors (RAC), Medicaid Integrity Contractors (MIC), and Zone Program Integrity Contractors (ZPIC).
  • Our programs and services increase profitability and ensure that all authorized claims are collected and processed to the appropriate entitlements.

This is a needed basic service for all claims processing centers such as third-party administrator (TPA)/Clearing Houses/Adjudication centers.

In our experience providers typically send their hand-written claims, to processing centers which can’t be processed through auto adjudication software unless they are converted into electronic versions.

Our experienced data entry operators are proficient in achieving high efficiency in Key From Image (KFI) functions with 99.5% accuracy and average productivity of 250 forms per eight hour shift.

We also provide mail-box function services to help our clients collect hand-written forms through courier services to complete the scanning process in our facility.

  • HCC-Coding Services to complete submission to RAPS / EDPS well-before the prescribed time-frames.
  • We conduct proxy or mock Risk Adjustment Data Validation (RADV) audits on the lines of CMS-RADV Audit Contractors for determining vulnerabilities in real time audits and recommend measures to ensure compliance with applicable statutes.
  • This initiative helps MAOs to keep tab on their liabilities for penalties and sanctions which may arise out of real time audits.
  • We also conduct 360▫ full performance analysis of:-
    • Panel-providers to ensure appropriate Clinical Documentation and Coding team performance for accuracy of coding process
    • Communication channels between Clinicians and Coders for appropriateness of prescribed PQP
    • Data Submissions Team to ensure that coding data are submitted to RAPS/EDPS in prescribed time lines.
    • Patient Encounters to see that follow-up of patients from plan happens as desired to enable the patients to stay healthy and stay subscribed with the plan
    • We also offer -Star Rating and HEDIS Data Abstraction Services for entitlement of Quality Performance Bonus (QPB) by helping you get the star rating score of 4/4.

Medical Necessity Audit Services (Utilization Reviews) Coding and Billing Accuracy has now become of subsidiary importance. Payers including the Medicare are seen and all set to process the claims based on the Medical Necessity of the services given rather than Volume Based payments. Value Care Payments Versus Volume Based payments is becoming the rule of paying the providers.

We help RAC/ZPIC contractors to determine validity of the provider’s claims based on Evidence Based Medicine rules such as MTUS guidelines (Medical Treatment Utilization Schedule) or InterQual (McKesson Software) Medical Necessity determining tools to determine appropriate utilization management and reviews.

Augustus HCS is open to work on contingency sharing basis with various recovery audit contractors.

  • Helping providers for Advanced EMR-MU-Stage 2+ through Clinical Data Abstraction services; to ensure the compliance with mandatory standards of Clinical Documentation for establishing Medical Necessity and optimum Utilization Review Compliance for easy walk during RAC/ZPIC audits.
  • Comment: This was moved from the Why Choose Us page as it is a description of a service.