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Netwerkes with Automated Payer Contract MonitoringContract monitoring integrated into the EDI workflow

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Current Contract Monitoring MethodsPayer contracts are complex. . .• Manual reviews of multiple

contracts are time consuming • Compliance is difficult• Contracts are not always defined clearly,

grey areas exist

Verifying payment accuracy. . .• Variances are difficult to detect

• Especially in environments with high claim volumes

• Manually preparing, submitting andtracking appeals is time consuming

• Inefficient processes delay paymentand impact cash flow


Current Contract Monitoring Methods

Practice Billing Staff

•Coding•Claim prepared based on manual review of payer contract

•Claim submission

Payer

•Claim rejected

Claim Rejected

Claim Accepted

Claim Submitted

•Claim accepted•Reimbursement sent

•Claim review•Manually check if rejection is due to non-compliance with contract terms

•Manually prepare appeal, or correct claim

•Resubmit

•Manually check if reimbursement is according to contract terms

•If underpayment, manually prepare appeal

Appeal

Appeal

• Reliance on manual processes

• Processes prone to human error

• Great potential to overlook lost revenue opportunities

• High staff burden

• Process not integrated into current automated workflow processes


What if There Was a Better Way?Q: What if. . .• Claims were automatically checked for payer contract compliance before

submission?• Reimbursement amounts were automatically verified for consistency with payer

contract terms?• Contract-based appeals were automatically managed?

• Increase operational efficiencies• Quickly identify underpaid claims• Improve cash flow• Further leverage your EDI data stream

A: You Would. . .

Netwerkes Clearinghouse Services


Netwerkes Clearinghouse

Netwerkes Can Help You:• Improve the quality of every transaction by automating existing business processes and

reducing errors which can help you reduce your A/R days.• Integrate seamlessly into a variety of office workflows including Practice Management

Systems.• Boost accuracy and efficiency with access to real-time information via a web-based

model.• Build unlimited custom edits that check against the rules that apply to specific payers.• Leverage our complimentary lifetime data warehousing for all your electronic files. • Come closer to collecting the entire amount due based on your payer contractual

agreements.

Netwerkes is a web-based clearinghouse that provides primary and secondary electronic transmissions, electronic remittances, eligibility verification, claim status, and much more to help you supercharge your revenue cycle.


Core Netwerkes Functionality

Functionality Details

Primary Electronic Claims Submissions (837 I, P, D)

• Reduce the number of errors, rejections and denials• Create unlimited rules and edits for your claims at no additional charge • One application to transmit UB, CMS 1500, and dental claims so you can track the

status of your claims at all times.

Secondary Electronic Claims Submissions (837 I, P, D)

• Create secondary claims with the click of a button• Auto-populate the CAS codes for all electronic secondary claims• OptumInsight prints and mails secondary claims along with the original 835 to any

payers that are unable to accept electronic secondary claims • Delivery of both printed and electronic secondary claims guaranteed

Electronic Remittances (835)

• Receive electronic remittance from all payers that offer electronic 835s• Automatically post 835 files• Each remittance is attached to the original claim and can be accessed at any time to

speed response time from payers

Eligibility Verification (270/271)

• Run real-time reports directly from the user interface• Choose either real-time or batch verifications• Transactions can be stored for one year and can be viewed at no additional cost

Claims Status Inquiry (276/277)

• Schedule automatic reports on the status of claims based on your average A/R days with each payer to see sooner if your request was accepted or denied

Netwerkes with Automated Payer Contract Monitoring


Netwerkes with Automated Contract Monitoring

Automated Contract Monitoring Can Help You:• Manage payer contracts from a central location and quickly identify underpaid claims.• Streamline your contract monitoring and appeal generation with automated variance

detection.• Systematically review every payment for proper contractual reimbursement.• Increase revenue through appeal and underpayment recovery.• Discover areas to improve fee schedule accuracy through greater transparency of what is

billed and what is allowed.• Identify specific elements of underperforming contracts to negotiate more favorable payer

agreements. • Model what-if scenarios and ideal contracts in relation to current rates.• Increase operational efficiencies.

Automatic payer contract compliance monitoring integration with Netwerkes allows you to identify claims payments that are inconsistent with your contractual terms and generate contract-based appeals directly into our clearinghouse service workflow.


Enriched EDI Stream

• Professional and facility clinical editing

• Contract monitoring for professional claims

• All integrated into the EDI data stream

• Charge entry• Charge entry work queue• Charge/ postings/ claims

processing

Practice Management System / Hospital

Patient Accounting• Claims

adjudication

Payer

• Professional & facility claims• Medicare & commercial payer

clinical edits• Checks against claim history

Clinical EditingClaimsManager

• Reviews claims for ANSI X12/HIPAA editing

• Send claims to ClaimsManager for clinical editing

• Presents edits for correction• Sends claims to payer• Sends claims and remittance to

ContractManager for variance detection and appeal processing

NetwerkesClearinghouse

• Professional claim payer payment variance detection

• Automated appeal processing

Contract MonitoringContractManager

ClaimsClaims &

Remittance

Claims &Remittance

Claims &Clinical Edits

Remittance Information,

Denials, Rejections


Automated Payer Contract Monitoring within the EDI Data Stream

• Available via a web-based delivery method that helps you boost accuracy and efficiency by providing access to real-time information

• Automated payer contract monitoring capabilities are integrated directly into the clearinghouse portal• You can be up and running in a matter of weeks with OptumInsight managing the infrastructure

Easy Integration ,

Implementation

• Automated payer contract monitoring replaces your manual payment review process• Payments that are inconsistent with your contractual terms will be cited, supporting documentation will

be prepared, and an appeals package will be created• To validate underpayments and appeal, streamlined access to appeals workflow is provided, including

remit data and reports

AutomationEfficiencies


Automated Payer Contract Monitoring within the EDI Data StreamIncrease Revenue Potential• The connection between what you bill and what you’re

reimbursed for can be more certain.• Ensure payer adjudication is processed correctly based on

contract terms. Uncover incorrect payments based on payer mistakes which can lead to additional revenue.

• Calculate the expected payment or net revenue prior to submitting each claim. By comparing results with your A/R, you can gain valuable insight into your A/R picture and begin forecasting revenue.

• Access Netwerkes’ comprehensive account reconciliation process which addresses primary payer A/R issues, accelerates secondary billing processes and prevents denials by facilitating accurate claims submission in compliance with commercial and Medicare requirements.

Automated contract monitoring through Netwerkes helps you get paid what you deserve

Payer accuracy rates range from 77 percent on the low side to a little over 98 percent (Medicare) on the high side.*

If your practice was entirely Medicare, you’d still face underpayments of almost 2 percent of your allowables.

Example:A practice bills $100,000 in Medicare claims annually. Identifying underpayments would results in $20K of revenue.

*American Medical Association’s 2010 Health Insurance Report Card*

Netwerkes with Automated Payer Contract Monitoring Workflow



Contract Monitoring capabilities available from single point of entry.


Netwerkes with Automated Payer Contract Monitoring ― Claims Submitted

Claim detail screen shows the total number of claims to be reviewed for contract monitoring purposes and for expected reimbursement.


Netwerkes with Automated Payer Contract Monitoring ― Remittance

Access remit data and see when remits were sent.


Netwerkes with Automated Payer Contract Monitoring ― Remits Status

From the claims details screen, see when remittance is available. Claim is ready to view if variance exists.


Netwerkes with Automated Payer Contract Monitoring ― Reports

Access payer dashboard report to get a snapshot of amounts appealed, billed and much more.



From Netwerkes, gain direct access into contract monitoring capabilities, including appeals and variance details.


Netwerkes with Automated Payer Contract Monitoring ― Appeals

From Contract Manager, select lines to appeal.


Netwerkes with Automated Payer Contract Monitoring ― Appeals

For a quick and easy appeals process, custom appeal letters are generated for you.


Netwerkes with Automated Payer Contract Monitoring ― Appeals Letter Example

Appeal letters are generated allowing for customizations and edits.

Thank You.

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