New Virtual Examiner® and Claims Audit Tool Solution Suite Featuring SymKey® Automation

This past July, a large Medicaid health plan licensed the Virtual Examiner® (VE) and Claims Audit Tool (CAT) solution featuring SymKey® Virtual Auto-Post (VAP) automation for the QNXT claims system. This cost-effective integrated solution will help the client to realize potentially millions of dollars in overpayment and rework savings, and generate significant ROI. It will enable the health plan to efficiently and effectively process, monitor, review, analyze, and report on:

  • The appropriateness of commercial, Medicare, and Medicaid claims billing
  • Potential fraud, waste, and abuse
  • Claims processing and payment accuracy
  • Pre- and post-payment claims audit results

In addition to CMS, AMA, Medicare, and other industry standard coding edits, various state-specific Medicaid coding edits are also available (including over 2 million Medi-Cal edits). It is the only solution in the marketplace that provides the capability to automate the posting of both coding edits from a code editor (VE) and error corrections from claims audit software (CAT) directly into QXNT. This streamlined workflow enables clients to save significant FTE hours in manual posting efforts and frees up resources to spend more time on researching and following up on non-routine/complex edits and errors. VE’s extensive fraud, waste, and abuse reporting and provider profiling offer additional savings opportunities and the ability to combat fraudulent providers and billing schemes.

How Does It Work?

The VE-CAT-VAP prepayment claims process works as follows:

  1. Claims data is extracted nightly from QNXT into the dedicated VE/CAT server
  2. VE runs each evening to review prepayment claims (and related historical claims):
    • Any routine/standard edits identified by VE are posted directly in QXNT via VAP
    • CAT integrates with VE so all edits identified by VE will display to auditors when reviewing claims in CAT.
  3. CAT runs each morning and auto-assigns errors based on audit filters configured for auto-audit
  4. Auditors perform their daily audits using CAT, utilizing CAT audit flags, audit filters and random sample filters to review problem areas, known issues, and to identify new problem areas and issues
  5. Corrections identified in CAT are applied in QNXT:
    • Coding edits and error corrections identified in CAT that can be safely and reliably applied are sent to VAP for auto-posting into QNXT
    • Any remaining edits and errors are manually processed/corrected by auditors/examiners, depending on the client’s preference and workflow

This unique solution will further serve as a compliance and educational tool to claims staff and network providers by presenting information in formats that will help drive improvements in claims billing, processing, and payment accuracy.

HCIM co-developed Virtual Auto-Post with PCG Software and is a reseller of both Virtual Examiner® and Claims Audit Tool. Virtual Examiner® is a registered trademark owned by PCG Software, Inc.

QNXT is a trademark owned by TriZetto Corporation. HCIM is not an official partner of TriZetto, and TriZetto does not sponsor or endorse our materials, goods, or services.

About HCIM

Since 2000, HealthCare Information Management, Inc. (HCIM) has delivered expert consulting services and robotic automation tools for small to mid-sized healthcare payer and managed care organizations. Our concierge consulting services include everything from core claims system procurement to go live, including configuration, migration, upgrades, reporting, benefits and fee schedules, user training, and project resourcing. We also offer strategic consulting in the areas of value based payments, population health, medical management, medical loss analysis and recovery, care management, provider contract modeling, data analytics, and business process reengineering/analysis.