patient responsibility & payer pre-billing requirement ......x 100,000 tests x $650 average...

Patient Responsibility & Payer Pre-Billing Requirement Impacting Your Bottom Line? Engage Physicians and Patients with Patient Access Solutions & Analytics To Improve Revenue

Quadax Benefactor Session Tuesday, April 30 8:30AM – 9:20AM

CLAIMS MANAGEMENT

Market Trends & Challenges

9 in 10

7 in 10

Healthcare consumers would like pricing

information in advance of care

Patients are more likely to use a provider or service

that estimates out-of-pocket expenses upfront

Highdeductiblehealthplanscontinuetorise–in2019expectedtobeover60%oftotalemployeeplans

•  Steadyincreaseinpriorauthorizationandmedicalnecessityrequirementsforcomplextesting

•  Traditionallyaverymanualanddisconnectedprocess

•  Clinicalrequirementschangeoften,requiringasignificantamountoftrainingandeducationforprovidersandstaff

3:5,000perday(100,000permonth)

AverageAllowable:$650pertest

•  PhysicianOrderingportalbuiltonSalesForce•  Withoutintegration,manualPatientAccessprocesswas

timeconsumingandstillresultedinhighnumberofencountersabandonedasself-pay

•  Evenwithmanualprocesses,35%oftheiraccessionshadmissingorinvalidpatient/insuranceinformation

•  Increasingnumberofdenialsduetomissingpriorauthorization/statementofmedicalnecessity

Rejected–Badinfo

65% 35%

CleanEligibility

Aninefficientprocesswithsignificantback-and-forthwithpatientanddoctor.

Highnumberofabandonedencountersincorrectlyconvertedtoself-pay

Patient Physician OrderingPortal LIS PatientAccess&Billing

https://www.beckershospitalreview.com/healthcare-information-technology/the-api-revolution-in-healthcare-s-evolution.html

• 

• 

Healthcare service provider application/s

APIs connect processes, services, content, and data

AdvancedEligibility

You Us

API

UI

Hybrid

Patient Physician OrderingPortal LIS PatientAccess&Billing

Servicesintegratedatpointofdecision(flexibility:patient,physician,LIS)

17 ©2018Quadax,Inc.

EligibilityandcoverageatorderentryPatient’sinsurancefromorderentryisusedtocreateareal-timeeligibilityresponseviaAPI.Presentseligibilityanderrorstoaportaluserearly–beforeorderisevencompleted.

18 ©2018Quadax,Inc.

InsuranceDiscovery

Whendataorcoveragewasunknownorinvalid,insurancediscoveryfoundcoverage,inreal-time–beforeanorderwasevencompleted.Insurancediscoveryreducesnumberofclaimsrejectedformissing/badeligibility–from35%to21%.

inself-payanduncompensatedaccounts

40%reduction

CleanEligibility

65% 35%

Rejected–Badinfo

CleanEligibility

83% 21%

Rejected/BadInfo

Before:

After:

19©2018Quadax,Inc.

Auto-PlanSelectionandPriorAuthorization

1.  SpecificInsuranceautoassigned

2.  LookupAssociatedPre-Claimclinicalrequirements,e.g.priorauthormedicalnecessity

3.  Helpsdriveworkflowanddenialavoidance

Rejected–Badinfo

usingpriorauthtostayinformedofpayerclinicalprograms

26%Fasterpayment

Billing ID 127

Payer Aetna

Plan PPO Choice Plus

Pre-Claim Requirements

Prior Authorization Required Statement of Medical Necessity

PatientOut-of-PocketEstimation

•  Benefitsderivedfromeligibility

•  Costderivedfromexpectedamountsoraverageallowablebypayer/plancontract

inadditionalreimbursementsper

monthduetoinsurancediscovery

inadditionalreimbursementsduetodenialavoidance

divertedtohighervaluetasksdueto

operationalsavings

4%(decreaseinauth/mednecdenials)x100,000testsx$650averagereimbursable

14%(decreaseinbadinfodenials)x100,000testsx$650averagereimbursable

thisisbasedonassumptionthatroughlyonly20%ofbadinfoaccountswerehandledbyteam

Thank you.