"Many healthcare organizations face significant challenges as they ramp up their revenue recovery processes. While there are many components revenue recovery cycle, one of the most significant components is the need to efficiently manage challenges associated with provider appeals of reported claims. Inconsistent determinations and insufficient supporting documentation can significantly delay the recovery timeline and cause MCO’s to unnecessarily review and resubmit claims as part of the appeal cycle."
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"Many healthcare organizations struggle with ambiguous, misleading and/or contradictory language in their provider contracts, leaving stakeholders on both side of the relationship frustrated in efforts to define intent. Compounding the problem is the occasional absence of qualification of services. In addition, health plans too often find that business rules of these contracts exceed their technical capabilities to reprice these rules."
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"All Healthcare Organizations struggle with large amounts of data. Protecting, managing and creating this data into information economically is a major hurdle all healthcare organizations must clear. This white paper focuses on new tools available in SQL Server 2005 that help improve processes associated with data loading and transformation."
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" Claims overpayment audits and recovery processes are common to managed healthcare organizations. This process, nearly always conducted on a retrospective basis, seeks to identify over/under payments on claims followed by an effective course of collection on overpayments and resolution of underpayments. Retrospective audits can actually undermine a plan’s standing in the marketplace, as they unnecessarily highlight payment errors, create additional work for all stakeholders and cause angst across the provider community resulting from a payer’s recovery efforts. "
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