Summary:

Code auditing work swamped the nine-person claims staff of one of Florida’s largest healthcare systems. Virtual Examiner banished the paperwork and integrated seamlessly with existing processes.

Background:

Memorial Healthcare System has provided healthcare services to South Florida residents for more than 50 years. Its flagship facility, Memorial Regional Hospital, located in Hollywood, Fla., is one of the largest hospitals in the state. With patient volumes rising, the health system found itself challenged to keep up with a high number of

changes in coding, coverage, and payer guidelines to follow.

Situation:

The health system’s nine-person claims department performed code auditing for nearly 35,000 covered lives via a paper-based method. Quality control thus became the responsibility of each claims specialist while entering information into the system. The paper-based process often revealed limitations when a claims history review was requested. There was no easy way for specialists to decide, for example, whether the file they were looking at was a

duplicate or whether the patient was eligible or insured. Billing matters were likewise impossible to track accurately, particularly with regard to accidentally overpaid or duplicate bills.

PCG Solution:

The health system’s nine-person claims department performed code auditing for nearly 35,000 covered lives via a paper-based method. Quality control thus became the responsibility of each claims specialist while entering information into the system. The paper-based process often revealed limitations when a claims history review was requested. There was no easy way for specialists to decide, for example, whether the file they were looking at was a

duplicate or whether the patient was eligible or insured. Billing matters were likewise impossible to track accurately, particularly with regard to accidentally overpaid or duplicate bills.