What is Exception Management?
Exception Management is to claims processing what patient triage is to the emergency department at a hospital. In much the same way that patient triage uses established protocols to handle specific situations, Exception Management applies payor-defined logic to validate, segment and route transactions in the most efficient and cost-effective manner. Clean claims are sent to the payor host system for processing, claims with specific types of errors are sent back to providers for edits, while other error types are placed in queue for analysis. The result is higher first-pass rates, as well as a streamlined and cost-effective process to handle claim errors.

Claims processing systems are designed to efficiently process claims – except for claims that are in an incorrect format or when claims contain errors. It’s these exceptions that quickly erode efficiency levels and escalate costs. With traditional systems, each exception typically costs $5 – or more – in staffing salary costs alone to resolve and process. This high cost results from the lack of processes and tools that payors have to manage these claims. The majority of payors focus on increasing the efficiency of processing clean claims, while they relegate the handling of exceptions to inefficient manual processes to resolve.

Reduce Claims Error Handling Costs by 99%?
By triaging claims with Exception Management, payors have the tools to handle claims errors in a more cost-efficient manner. By employing Exception Management, payors can reduce the cost of handling exceptions to 25 cents per situation. That’s a savings of $4.75 for each claim processed. With the typical payor handing hundreds of thousands – if not millions – of exceptions each year, the cost adds up quickly, and each exception takes a small bite out of the bottom line.

One of the premises behind Exception Management is that, despite provider training initiatives, payors cannot control how providers create and submit claims, but payors can control how they handle claims with errors. By reducing the errors that are handled internally within their organizations, payors can reduce the costs of claims processing.

Most importantly, Exception Management provides payors with the processes and tools to manage errors. While catching an error is important, it’s resolving the error where the most costs are incurred. The low per-transaction cost of catching errors using Exception Management enables payors to apply strict validation logic to transactions to allow only the clean claims to reach the host system. And, the flexibility of the Exception Management platform allows payors to easily define how transactions are handled, such as sending complex errors to costly claims auditors for review vs. having more routine errors resolved by lower-cost data correction review technicians.

Perimeter Processing
Paying pennies to process claims – instead of dollars – is made possible by the way Exception Management handles transactions using Perimeter Processing, the term used to describe the infrastructure that forms the foundation for the claims triage process. Perimeter Processing employs a Web-based transaction exchange portal (TEP) to manage the flow of inbound transactions (claims, status checks, enrollments, eligibility, etc.), and outbound transactions (remittance, authorizations, etc.). In essence, Perimeter Processing includes the infrastructure and front-end interface that enables organizations to view, measure and manage their claims data.

Create Business Rules on an Agile Platform
Don’t settle for a so-called “business rules engine” or a simple claims scrubber. Workflow management and error routing can be implementation and integration nightmares. With AdminisTEP's Exception Management capabilities, you get the ability to select and create custom business rules that maximize the pass rates of clean data and route the errors when, where and how you want them so that you can fix them in the fastest and least expensive way possible. It's a powerful workflow management tool that’s tied to the transaction data and error correction at the data element level – all traceable, assignable, manageable, and auditable. Readjust how you run your business in a flash using agile technology that produces results. No need to invest the time and money to reconfigure core claims processing systems, just focus on getting clean data, lowering processing times, and getting access to the metrics that drive your business.