A California based TPA selected expEDIum Claims Portal and reduced work hours by 35%

Doctor's Business Services (DBS), a San Juan Capistrano, California based Third Party Administrator (TPA) manages funds for number of physician practices who are under capitation contracts., Using a legacy AS 400 IBM system for claims processing and claims adjudication for the last 20 years they became unhappy with their system which was not meeting their ongoing requirements to run the practice more efficiently and to be compliant.

They were facing the following issues and had requirements:

• A paper based system requiring personnel to manually process the claims
• The system was slow and cumbersome
• Maintenance of the legacy software was cost prohibitive
• Inefficiency in the workflow due to manual integration of data from multiple systems
• Standard EDI and electronic claims (837P) were not supported
• Single solution for processing claims, adjudication and managing authorization/referrals
• A cloud based Software which is flexible and can fulfil their current and future needs and requirements
• A Cost effective, easy to use software with high quality of customer service
• Being able to support multiple accounts
• Being able to receive and process electronic claims (837P) from practices

They were searching for an appropriate solution to fulfil their requirements and had spent quite a bit of time to find the right solution for the right price. They had evaluated various claims processing solutions in the market, but all were either cost prohibitive or inflexible on custom requirements. DBS implemented expEDIum Claims Portal in Nov 2012 after iTech customized eCP solution to meet their unique needs.

• iTech implemented a customized eCP solution that is completely standards based (HIPAA and X12n EDI)
• Single solution for managing complete claims life cycle and managing authorizations/referrals
• Completely transformed from a largely paper based office to electronic office
• Direct electronic claims (837P v5010) submission by providers
• Solution detects/validates any errors in the claims while submitting it into the system, and hence reduces in manual claims review process
• Increases the efficiencies in claims adjudication and in payment cycle
• A customized prior-authorization/online referrals management feature is in the software that has several auto fill/look-up feature and hence streamlines the process
• Direct online referrals/prior-authorization request by practices and receive the response on their respective accounts
• Introduced Manager Module where data from various accounts are integrated, manages various activities, better aggregated data analytics and consolidated reports across clinics
• A very easy to use and cost effective solution with excellent service or support

• The biller processes over 1300 HCFA claims a month from about 40 clinics; have processed over 40,000 claims with total charges of about $20 million since the inception through this system
• Over 8000 online referrals/authorizations have been performed since the inception
• Moving to newer technologies have helped them with longer solution shelf life and business continuity
• The total work hours cut in by 35% (moving from paper to electronic, among other reasons). The staff is able to concentrate on other aspects of the business such as compliance, client training, increase business and marketing

The solution is being used by a couple of different TPAs with 100s of providers, processes and adjudicates thousands of claims. One of the TPAs uses our system to send 1000s of encounter data to Anthem of California and another uses our customized solution to collect triage referral requests and authorizes them; assigns the triage authorization to a recipient hospital. Receives and adjudicates claims from these recipient hospitals.