The Problem

Did you know that if you don't have an on-going overpayment review process in place that you are losing a minimum of 5% of your annual claim expense dollars? During these times of low reimbursement and tight premium dollars, this loss can be deadly to your bottom line. Contract terms are not easily quantified by systems and people, try as they might, are only as accurate as their training and oversight allow, and it's only gotten worse for payors under the Affordable Care Act.

Our Overpayment and Recovery System (OaRS) can do interactively and retrospectively what you don't have the time, staff nor inclination to do. All claim shop directors know that when they get stretched for staff, the first positions to get folded back into processing are the trainer and auditor. Like it or not, quality sometimes takes a back seat to productivity.

We have all lived with spending more claim dollars than needed because we had to "push the paper". Pilot Information Systems can solve this problem for you. OaRS can be interfaced to your existing iSeries based claims system to produce recommendations in real time. OaRS also includes a batch oriented system which can scour your claims history for overpayments in over 25 areas. The system identifies money you already left on the table and permits you to recover the expense without any human intervention by utilizing its built-in reprocessing module.
 

Our Solution

Up until now your choice in the identification of overpayments has been limited to one of three offerings: 

  • pre-packaged PC software that offers little in the way of customization to meet your business needs and often requires expensive database servers and staff to run it 

    -or-
  • huge consulting firms that don't provide personalized service and take a "one size fits all" approach,  in addition to requiring minimum dollar thresholds just for the "privilege" of doing business with them

    -or-
  • software from the industry giants that can cost well over a million dollars to implement and operate on remote servers which require external network calls, often leaving the claim examiner watching the hourglass for up to a minute before it returns its results. You also need to factor in the time and cost of interfacing their system to your EDI and online claim maintenance programs.

 

Our solution is to offer you our claim editing software for installation on your server for one low monthly fee. 

 

 

Real-time interactive IBM iSeries based claim editor

OaRS is written in native iSeries programming languages, which means two things: speed and security. When interfaced to the host claim system, the interactive claim editor returns its recommendations instantly. OaRS resides on your equipment and keeps your data secure at all times since it never leaves the platform.

 

Our batch solution

Included in the license fee is a very sophisticated batch application which allows you to go back over claims history and mine for overpayments still lingering in your database. Many of our installations use this feature to identify and recover claims which slipped through the cracks or were glossed over by examiners when they were initially entered.  The batch system also has the ability to reprocess or "take back" the claim expense by reversing those claims found to have been paid in error.

 

Software as a Service (SAAS)

Using this method, your IT department would automate the collection of claims that need to be analyzed  (be it daily or historical) and send the data through a secure VPN connection directly to our server. Once the claims are processed, a results file is placed back on your server where they could be printed out for manual adjusting or automatically applied via internal scripts or update programs. Our interface uses the latest RESTful technology while utilizing JSON as the data interchange. Compare this to the resource and network intensive SOAP and XML interfaces that our competitors require their customers to use.

 

 
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