Exception Management is custom workflow for identifying, segregating, and routing transaction errors to the most cost-effective point of resolution.

Exception Management is the most transformational development in end-to-end transaction administration since software-based claims adjudication was introduced 20 years ago.

For years, until now, the overwhelming conventional wisdom has been to maximize the good claims and speed them through as fast as possible while just letting the bad claims fall out into a pile to be dealt with manually by highly paid resources. Errors were commonly fixed individually, and on-the-fly, by experienced claim workers. Group routing, batch-fixing, knowledge management, and upstream rules-based processing weren’t feasible.

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.

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.

So why not start from the beginning? The first and best chance to identify and correct transaction errors is at the point of submission. For providers that means immediate feedback on what errors could delay adjudication. For payers, that means taking control of the transaction data at the same point you take ownership of the transaction. For TPAs and channel partners, it means process-optimizing the duties that have been assigned to you and getting the claim back for adjudication faster. For everyone it means applying rules and logic much sooner in the transaction lifecycle, which translates to faster turnaround times and lower costs.

Decide the “who, what, when, where, why, and how” questions about routing data errors. Fix common provider and member errors automatically, in batches, real-time. Track and reconcile critical control points, or all the control points for that matter. Our basic set of reports gives you visibility into exactly what path every transaction takes, and you can change or reroute data on demand. When combined with our Digital Mailroom for Healthcare services, you can even treat paper transactions the same as electronic ones. Imagine full transaction inventory reconciliation across your infrastructure, regardless of the origin of the transaction, done in real time, from the moment of submission. Wow!

Why not 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.

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 for resolution.

One premise 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 that 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.

Let’s face the truth – providers, your rejected claims cost you cash flow, and payers, your rejected claims cost you provider relations goodwill and headaches with members. But the reality is that AdminisTEP finally allows providers the see what’s wrong with the claims before or as it’s submitted to drastically minimize the number of claims that get held up for minor errors, and that means better cash flow. Payers can stop pestering providers with rejected claims that failed on a technicality like slightly bad provider or member information, and that means happier providers and members which, in turn, means more providers and members. And isn’t that the goal? More participating providers and happier members is the foundation for successful growth and market presence.

Finally, don’t just manage the routing and workflow of bad claims – do it for ALL types of correspondence. AdminisTEP is capable of coding outgoing correspondence so that you can easily route responses and store incoming data to a repository for maximum distribution. From medical records requests and retrievals to grievance and appeals processes, AdminisTEP keeps the information at your fingertips so that you can maintain goals for turnaround times throughout all the ancillary processes for claims lifecycle management.

Call us at 214-440-3100, or email us at takethenextstep@administep.com.