A California-based TPA selected expEDIum Claims Portal and reduced work hours by 35%

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expEDIum has been great to work with on multiple levels. Aside from standard billing, we needed a new claims payment system for a small IPA we run. When we looked around at companies providing that software, we found they were all cost-prohibitive and unwilling to get creative in their pricing for a small IPA. We looked at dozens of companies and were getting frustrated until we came across expEDIum...

Charlie Hearn, President, DBS, Inc

Doctor's Business Services (DBS), a San Juan Capistrano, California based Third third-party administrator (TPA) manages funds for a number of physician practices that are under capitation contracts., Using a legacy AS 400 IBM system for claims processing and claims adjudication for the last 20 years they became unhappy with their system which was not meeting their ongoing requirements to run the practice more efficiently and to be compliant.

They were facing the following issues and had requirements:

  • A paper-based system requiring personnel to process the claims manually.
  • The plan was slow and cumbersome.
  • Maintenance of the legacy software was cost-prohibitive.
  • Inefficiency in the workflow due to manual integration of data from multiple systems
  • Standard EDI and electronic claims (837P) were not supported.
  • Single solution for processing claims, adjudication, and managing authorization/referrals.
  • A cloud-based Software that is flexible and can fulfill their current and future needs and requirements.
  • A Cost-effective, easy-to-use software with high-quality customer service
  • Being able to support multiple accounts.
  • Being able to receive and process electronic claims (837P) from practices.

They were searching for an appropriate solution to fulfil their requirements and had spent quite a bit of time trying to find the right solution for the right price. They had evaluated various claims processing solutions in the market, but all were either cost-prohibitive or inflexible on custom requirements. DBS implemented the expEDIum Claims Portal in Nov 2012 after expEDIum customized the eCP solution to meet their unique needs.

Solution Implemented
  • expEDIum implemented a customized eCP solution that is entirely standards-based (HIPAA and X12n EDI)
  • Single solution for managing complete claims life cycle and managing authorizations/referrals.
  • Completely transformed from a largely paper-based office to an electronic office.
  • Direct electronic claims (837P v5010) submission by providers
  • The solution detects/validates any errors in the claims while submitting them into the system, reducing the manual claims review process.
  • Increases the efficiencies in claims adjudication and in the payment cycle.
  • The software's customized prior authorization/online referrals management feature has several auto-fill/look-up features, streamlining the process.
  • Direct online referrals/prior-authorization requests by practices and receive the response on their respective accounts.
  • Introduced the Manager Module, where data from various accounts are integrated, manages various activities, better aggregates data analytics, and consolidates reports across clinics.
  • A very easy-to-use and cost-effective solution with excellent service or support.
Return on Investment (ROI)
  • The biller processes over 1300 HCFA claims a month from about 40 clinics and has processed over 40,000 claims with total charges of about $20 million since the inception of this system.
  • Over 8000 online referrals/authorizations have been performed since the inception.
  • Moving to newer technologies has helped them with more extended solution shelf life and business continuity.
  • The total work hours were cut by 35% (moving from paper to electronic, among other reasons). The staff can concentrate on other aspects of the business, such as compliance, client training, increased business, and marketing.

The solution is being used by a couple of TPAs with 100s of providers, processes, and adjudicates thousands of claims. One TPAs uses our system to send 1000s of encounter data to Anthem of California, and another uses our customized solution to collect triage referral requests, authorize them, and assign the triage authorization to a recipient hospital. Receives and adjudicates claims from these recipient hospitals.