2. Meet the Robot: Facets | QNXT | QicLink
Sal Novin: AVP Product Management – HPA Services

3. HPA Services | What do we mean by robot?
An automation service specifically designed for healthcare reimbursement
HPA Service Robot works through user interface and performs work that is indistinguishable from work performed by a person
Autonomic Computing | Artificial Intelligence | Machine Learning
Not a macro tool, auto-key tool, or automation tool
An outcome-focused technology based outsourcing service

4. HPA Services – Video Demonstration

5. HPA Services – Key Benefits
Faster Processing
Up to 20-30X faster than a human.
Consistent Results
Zero variance from DLPs
Fewer Errors
99.97% first pass Financial Accuracy
Scalable
Access to unlimited staff
Analytics
Root Cause Analysis | Big Data
Immediate ROI
Implement in <6 weeks
Contingency Pricing
Pay for only successful transactions
Volume Discounts
Save more as volume increases
Total Cost of Ownership
Labor Savings + Quality Savings

6. Evaluating Operational Impact
Straw Man ROI
Monthly Claim Volume: 75,000
Processing Speed: 15/CpH
Staff Hours: ~5,000
Daily Utilization: 7 hours
Required Number of FTEs: 29
Calculating Savings
Success Stories
BMS QNXT Client
45,000 Sequestration claims 8 days
BCBST
66,000 ITS Adjustment claims in 9 days

7. Experience Provider Matching – Selecting matching provider for claim7
© 2015 TriZetto Corporation
Provider Matching – Selecting matching provider for claim
Eligibility Matching – Selecting member for claim
837 Care Management - Encounter reporting
ABC Crosswalk – Creating and paying secondary claims
EAPG Pricing – Validating claim line data and applying pricing from a spreadsheet
Edit225DME – Researching and applying authorizations for DME Rentals
Edit101 – Research and reconcile claim provider details either with provided information or EDI
Edit1111 – Okays 1111 edits, adjudicates and attempts to Pay the claim
Edit201 – Research and reconcile claim member details either with provided information or EDI
Edit205 – Researching and applying authorizations
Edit205NonPar – Researching and applying authorizations for non-participating providers
Edit224 – Deductible Research – Patient may have met deductible, amount may need to be removed
Edit225Anest – Apply manual pricing for specific anesthesia procedures
Edit225Nursing – Apply manual pricing for specific SNF procedures
Edit225Repricing – Apply manual pricing for inpatient and outpatient claims (excludes renal dialysis claims)
Edit236 – Researching and applying referrals for specific services
Edit334 – Researching and resolving MicroDyn APC Active pricer edits
Edit367 – Researching and applying authorizations (also uses CCMS application)
Edit519/532/533 – Researching and reconciling potential duplicate claims by paying or denying the claim
Edit311/541 – Processing claims according to the timely filing rules
Edit600 – Removing referrals for specific services
Edit610 – Analyzing service code hierarchy to reconcile authorized services from UM document and the claim
HCC/AHA – Processing personal health profile (PHP) claims
IHT Percentage Reductions – Applying MTR recommendations based on the iHealth report
LTSS – Processing claims according to TX Medicaid rules
Member Not Found/No Affiliation – Researching and adding members and Providers to claims
PCP Copay – Adjust copay on claims for primary care visits based on market standard, reversing claims where required
RemoveOOP – Removes patient's responsibility from claims
ReverseAndAdjustPrice – Reverses paid claims and adjusts pricing
ReverseAndRemove OOP – Reverses paid claims and removes patient's responsibility
ReverseAndRemoveReferral – Reverses paid claims and removes referral
Sequestration Pricing – Applying 2% reduction for Medicare sequestration
Split Year – Client was sunsetting MHC system – some claims had DOS starting before 1/12014 but ending on or after 1/1/2014. Since MHC should handle 2013 service lines, and QNXT handled 2014 service lines, the script needed to delete lines from 2013 in QNXT.
UnitsCorrection – Updates units on claim to match units from EDI
Update Providers – Update provider on claims with supplied information: Rendering provider NPI/ID, Pay-to ID/TIN/Address/Name
VaccineDenials – Denies service lines with flu immunization procedure codes
Validation – Data reconciliation between original EDI data and the imported claim
VOID – Voids claims in QNXT using a void reason crosswalk
Enrollment:
LIS Update – Reconciling LIS data between QNXT and EAM
XC – Facets XC Pre-Scrub (Member/Provider selection before moving into Workflow)
PDEM – Resolving Provider Demographics mismatches on claims (Provider selection)
PUNK – Resolving Unknown Providers on claims (Provider selection)
AGR – Resolving mismatched/unknown Provider Agreements (Provider selection)
DUP – Resolving possible duplicate claims by adjustment or denials
MM – Validating/updating claims with multiple modifiers
FREQ – Resolving Hospital claims frequency by adjustments or denials (similar to DUP)
MSRE – Updating Allowed Amounts for Multiple Surgery Reduction pends
MEXC – Reviewing claim notes for payment exceptions (Member)
PAUD – Reviewing claim notes for payment exceptions (Provider)
Review Subscriber Payment – Determining whether payment should be made to the Provider or Subscriber and updating Facets if needed
Entering Claim Lines – Entering and updating history claim service lines
COB Letter Notes – Adding notes for members/dependents whose COB Letters have been mailed.
Access Fee Adjustment – Claims identifiedfrom a worksheet or file matched to original claim in Facets to create adjustment. This crosses over to the main frame ITS piece, where an NF06 is created
Encounter Claims – Entering new claims from a spreadsheet into Facets
AUTH – Searching and applying authorizations to claims
HSRV – Searching and applying authorizations to claims – Health services review (same as AUTH)
DHH – Determining coordination of benefits for Medicaid and commercial contract benefits
DME Host SF Code Matching – Determining if DME charges are rental or purchase, calculating and adding allowed amount(s) to the claim if needed
Split Claims – Adjusting claims by splitting service lines and applying overrides
 Billing/Enrollment:
Cash/Payment Posting – posting member’s credit card payments in Facets
Commission Adjustments – posting commission adjustments from group to Facets
Refunds – posting refunds from Provider in Facets (has been duplicated for multiple providers)
VIP – updating member’s VIP type in Facets
Auto-Recovery Update – Updating member accounts for overpayments and reductions
 Provider Maintenance:
OON Providers – Updating Provider records with out-of-network agreements
New Group Setup – Creating new provider group records in Facets
Group Renewal – Renewing/updating provider group records in Facets.

8. Thank You