Welcome to Diamex Management

CLAIM PROCESSING

Diamex Management specializes in claims consulting to healthcare providers. Our experienced claims consultants will carefully assess every detail of your claim and the insurance carrier's denial in an attempt to determine the most appropriate and effective action to be taken on accounts placed with us. Further, we will research the most recent case and statutory laws, which support payment on your insurance claims.

Overview

We do pre-collections follow up for claims which have "reject/resubmit" status and have aged beyond 60 - 90 days and are not ready to be assigned to collections. We believe that there is significant value in pursuing these types of claims on behalf of your healthcare facility, particularly in the wake of resource limitations that can prohibit your facility from processing these claims with the same timeliness as the newer claims.

In spite of timely payment rules in many states, a common complaint of all hospitals is difficulty in collecting accounts, which are 60 to 90 days old. Many hospitals have a difficult time reprocessing such claims.

Our goal is to lessen the burden of un-collectible accounts on your facility's financial health.

Benefits from utilizing our services

An alternative to immediate collection agency placement.

We successfully secure full benefits of claims previously denied.

Provider can maintain good patient/provider relations

Overall improvement of financial performance, cash flow and profitability.

What Claims can be outsourced?

Pending Claims; which are past due 60-90 days
Denied Claims; due to incorrect contractual discounts & out of network reimbursement.

Our Solution

Collection of these accounts typically requires:

Submission of medical or operative records

Patient completion of coordination of benefits or other forms

Correction of improper billing information

Re-submission to the proper carrier.

Two-pronged strategy would be adopted.

To gather denial/rejections details, reasons, etc through follow ups

To take appropriate actions, i.e. re-filing of claims, etc

Follow Ups

We would track denials, log what has been denied, why, how, and when the claim was filed to the greater levels of details.

The reasons could be:

Coding: Denials caused by coding issues can include bundled codes, a diagnosis that is inconsistent with the procedure, and invalid codes or modifiers, etc.

Front Desk Issues: Registration, referral and authorization errors can contribute to denials. These errors can include a subscriber who is not enrolled, an incorrect claims address and lack of referral or authorization, etc.

Billing : Denials caused by billing staff can include keying errors, credentialing issues (a provider is not enrolled), incorrect monies transfers, inaccurate payment postings, duplicate claims, untimely filing, problem in filing paper or electronic claims, etc.

Insurance Company: Denials caused by an insurance company can include lack of medical necessity, lost claims, coordination of benefits, lapsed coverage, requests for additional information for claim adjudication and other related issues.

Keeping in view electronic transactions standards (276/2777) of HIPAA, we will get to the bottom of the claims status, & then will hit the claims accordingly which may include knowing:

Pre-adjudication (accepted/rejected claim status)

Claim pended for development (incorrect/incomplete claim(s) within adjudication process) or suspended claim(s) requesting additional information

Finalized claims. Further defined, finalized claims may have outcomes that include finalized rejected claim(s), finalized denied claim(s), etc.

It should be kept in mind that denials out of medical necessity (mis-coding of claims) will be easy to handle and collect. The denials due to timely filing and incorrect or incomplete information can turn out to be more problematic, especially for claims of a year old or more.

Re-filing of Claims

Reviewing the reasons for denial, making necessary changes and resubmitting the bills.

Requirement

Assignment of accounts at a specific interval

Hospitals would automatically refer accounts to MedLexis as they age beyond 60 days from date of service (or another mutually agreed upon time frame). Diamex Management would have the exclusive right to collect these claims.

Provision of billing/clinical information

The hospital would designate a specific individual to receive Diamex Management's requests for medical/operative or other records and who would provide EOB's, superbills, patient info sheet, etc.

A detail of pending claims (Claims-Open Claim Status Report)

Insurance related information, i.e. name, telephone no., website address, doctor/hospital subscription Id.

Patient related info such as name, date of service, date of birth, policy Id#, group, social security, billed amount, associated diagnoses & procedure codes and/or descriptions, etc

Doctor related, i.e. provider Id. Etc.

Date of submission histories for each claim

Details of pending patient responsibility claims (if any)

Billing Software:

Diamex Management will prefer to use its own billing software

Note:

The amount can be recovered, but the collectible will be less than the charged amount because:

Insurance companies reimburse less than what is charged, depending on plan participation.

There will be some charity care included which will never get paid.

In some cases, no payment will be forthcoming due to ineligibility, non-covered services and timely filing issues.

Charge Structure

Diamex Management's staff will conduct a brief review of claims status and work required. co will charge the hospital either:

A percentage of amounts collected

In the case of hospitals with significant billing/collecting problems, a fixed fee (intended to cover personnel costs and associated expenses) and a percentage of amounts collected.