Our copyrighted proprietary software is available for licensing to those organizations whose claim systems reside on IBM's AS/400^* and iSeries^* platform, including OAO Healthcare Solutions MC400^* managed care system.  

Interface

We will modify our Overpayment System to interface to your claim files at no cost to you.


Written to Perform

Mining for overpayments can be a very intense job, especially when sifting through millions of claims.  Our system was written with this in mind and includes routines that lighten the load on the host system. As a result, we have seen high end units process several hundred thousand claims an hour.

Our unique user interface, coupled with the platforms Open Query File facility, allows you to select on any field contained in your claim files using a variety of selection criteria including single values, ranges, wildcards, "contains" as well as exclusion clauses. This feature permits you to quickly audit specific groups, plans, members or just about anything else your claim files contain. 

User Definition

Most systems define duplicates as claims that have the same procedure, performed on the same patient on the same date by the same provider.  In our efforts to add flexible functionality, we leave the definition of duplicates up to you.

Our system currently allows users to define a duplicate by the use of nearly two dozen different selection criteria.  For instance, in order for a claim to be considered a duplicate, must the billed charges be the same on all potential duplicate records or can they be within a certain range, say, 15% of each other? 

Another helpful feature permits you to select overpayments using "like" procedures.  Many claim shops add prefixes to certain CPT^* and Revenue Codes, making them unique and unable to find matches.  We have incorporated logic that allows you to match on codes that have similar characteristics. For example, the system can be setup to match Revenue Code 360 with R360.

When is a Duplicate not a Duplicate?

Knowing full well that there are certain procedures that can be legitimately performed several times a day (such as radiology) prompted us to create a definition table where you can specify which procedures and/or modifiers are permitted to be billed more than once on a single day. This prevents you from informing your provider that they double billed on what turned out to be a legitimate claim. 

Professional, Institutional or Both?

One of the options we included is the capability to look for duplicates based upon the contents of your professional and institutional claims exclusively as well as the ability to cross reference both files. This allows you to find providers that are billing for the same service in different settings.

Reprocessing

Included in the system is a module that allows you to reprocess all of the duplicate claims that are discovered. This permits you to automatically reverse duplicates that have already been paid and gives you the ability to pend or deny claims that are waiting to be paid.  

In Good Company

Our system is installed at many health plans, TPA's and self-insured plans around the country and is fast becoming the de facto standard for duplicate claims identification on the IBM midrange platform.