Capabilities
Fraud Abuse and Waste Detection and Prevention
This problem is on a vast scale and cost billions of dollars to the exchequer. We collaborate with the payer organizations and support them to reduce fraud, abuse and waste utilizing our expertise in payer services and solutions.
The ambit of fraud schemes range from individual ventures to broad-based operations by an organization or group. Structured scandal has infiltrated the Medicare Program and few providers and suppliers have in the past impersonated as Medicare. Examples of Medicare fraud include:
Federal laws governing Medicare fraud and abuse include the:
• Physician Self-Referral Law (Stark Law);
• Social Security Act; and
• United States Criminal Code.
• False Claims Act (FCA);
• Anti-Kickback Statute (AKS);
Several fraud Preventions program are in place, however the overall efficacy of those processes is hindered by incompetent resources, insufficient training and lack of knowledge.
Detecting Health Insurance Fraud, Abuse and Waste using Analytics
R System is staffed with highly driven, professional, senior-level data analysts and statisticians; they have several years of practice leading health care fraud research, claims analysis and finding regulatory and statutory noncompliance.
R System provides consulting and supportservices in a wide variety of areas of analytics:
• We execute cutting-edge data analysis and innovative data science to spot and alleviate FWA. We develop analytics platform to detect swindle for the Centers for Medicare & Medicaid Services (CMS) on the HIX.
• By using sophisticated data mining solution and services, we can predict a potential fraud.
Revenue Cycle Management (RCM) and Account Receivables (AR) Solutions and services
We provide end to end services in RCM by leveraging our healthcare vast experience and experts in IT and Business Process Outsourcing services.
We apply our deep and wide range of experience, skills and technology to provide the RCM solution and services.
Patient Billing and Accounts Receivable Management: This includes payment posting, AR follow-up. There is a through remittance and claim searching and mining to link a remittance with claim.
Management of Denied Claims and Appeals: We provide services for managing the denials of claims and help you analyze the source roots of denials. We have expertise for following up with payers to rebilling with required appeals communication.
Medical Coding: Our knowledgeable coding teams have AHIMA and additional important endorsements and can manage entire data entry, ICD, CPT and DRG coding, as well as a series of coding specialties, as well as anesthesiology and surgery.
Billing and Corrections: The Billing management services consist of charge record, demographic and E-claim generation and charge description (CDM) master review.
Payer Analytics
The Patient Protection and Affordable Care Act (PPACA) have dramatically altered the US health Insurance landscape. Influx of previously uncovered population, new underwriting requirements will generate the demand for more information from varied resources mandating use of big data analytics more than ever before.
Membership management to Increase Retention & Reduce Attrition through Analytics
• Analyze the customer base and perform micro-segmentation
• Refining the consumer & member arrangement process to retain and involve and help to have more dedicated members
Health and Wellness Management
Lifestyle Risk Assessment & Profiling
Risk level Categorization
Wellness Program Management
Self-Assessment Tools & Wellness Library
Claims Analytics
Leverage claims data for advanced healthcare analytics to improve utilization, recovery and member management.
Provider management
Database management, credentialing, contracting services, pricing maintenance, and configuration assistto improve the business performance. Our healthcare payer analytics provide the deep dive that you need to discuss best rates with providers, ensuring superior care at reasonable prices.
Electronic Data Transaction Services
Reliable and fast data transfer between different stakeholders has always been a tough task and require a robust solution and expertise. The importance of accurate data transfer is most vital in the management of both Electronic Medical Records and health plans, reimbursement details. EDI application has demonstrated to both save time and money.
Payer and provider can perform their daily business by using various EDI transactions as:
| 270/271 |
Eligibility Benefit Inquiry and Response |
| 276/277 |
Claim Status Request and Response |
| 278 |
Authorization Request and Response |
| 820
| Premium Payment |
| 835 |
Benefit Enrollment and Maintenance |
| 837 |
Health Care Claim Payment/Advice(Professional, Institutional & Dental). |
Electronic Data Transaction Services surely boost quality with quantity, reduce administrative costs, substantial effect on the quickness of insurance reimbursement health care enrollment and maintain financial and business neutrality.
Our end to end EDI transaction services support to ensure that your EDI transactions are compliant with standards, regulations and up to mark as per payer requirements for scenarios including:
• To ensure EDI transaction’s integrity.
• Full coverage of requirements as per HIPAA Implementation.
• Financial balancing of claims or remittance advice.
• ICD9/ICD10, CPT, NDC etc. codes verification & validation.
• Line-of-Business testing.
• Trading Partner specific testing.
• Payer-Provider testing.
• Financial neutrality due to ICD 10 code implementation in 5010 version.