 Business Challenge
The client had requested replacing a paper-based HCFA 1500 claims processing
for physician practices with an automated, electronic software solution that adjudicated claims,
with the goal of verifying the CPT and other medical codes to optimize the payment
from payers and providing physician's with real-time access to their medical
claims processing.
Physicians were documenting the CPT codes and billing information on paper HCFA 1500 forms
and a courier was collecting these forms on a daily basis such that they can be brought
to the Billing House for the bill processing. Once at the Billing House, the bills
were manually examined to determine if more effective coding can be used to optimize
the reimbursement for the care provided. The CPT codes and billing information was
converted to the correct format and transmitted to the appropriate payer depending
on the patient's medical coverage. The Billing House adjudicated the medical claims
via standalone in-house application. Only month-end reports were provided
to the physicians.
 Solution
Internet application allowing Physicians to directly enter HCFA 1500 forms
using a browser has been developed. The billing and patient medical coverage
information is captured and sent to a central server. The Billing House then
adjusts the CPT coding as necessary and adjudicates the medical claims.
On the next step Electronic Data Interchange software is employed to exchange
claims and remittance advises with the payers. The physicians have on-line
access to the month-end and other reports, so there is no need to print and mail
them anymore. The application also generates and prints the Patient
and Courtesy Statements to notify the patients about the unpaid medical bills
that are not totally covered by their policies. Flexible reporting system
for the Billing House personnel is a powerful tool for financial analysis,
providing an easy way to generalize the Transaction/Aging info for any level
of organizational hierarchy.
Software and Services: ASP/VB, MS SQL 2000, MS IIS 5.0, Crystal Reports
 Benefits
The Medical Bill Processing system has dramatically decreased the costs comparing
to those of previous paper-based processes. The time required to fill out
a software based HCFA 1500 form was greatly reduced. Overall time of medical claims
clearance was significantly reduced as well. The accuracy of CPT coding has been
noticeable improved. One of the main advantages of using the new software is that
doctors are getting paid much quicker than before. The centralized database allows
real-time access to the key data for all parties involved, and simplifies control
and maintenance. The configurable multi-level security prevents from unauthorized
access and guarantees confidentiality of all sensitive information on all steps
of the medical claim processing. Multi-layer architecture provides scalable solution,
which can be deployed on a server cluster utilizing Load Balancing services,
and support as many users as required nationwide.
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