Best Practice Guidelines: Medical | Dental | Allieds

Responsible Roles

	Management Role: Check that all claims were sent before the end of the business day. Ensure all rejections have been dealt with daily. Ensure no “To be sent" or “flagged for submission" claims exist. Ensure the Billing Expert, and Credit Controller relationship is in place and maintain proper communication between them.
	Operational Role: Use validations and imported data to prevent rejections. Ensure all claims are sent daily. Follow up on all rejected claims or line items on the claims, make corrections, and resend claims to medical aids. (Complete the 4 R’s: Reverse, Redo, Resend, Resolve.) Ensure all claims are dealt with and that Approved-in-full claims are resolved to update the list, which the Credit Controller uses to follow up on outstanding claims.
	Operational Role: Ensure all possible methods are used to correct claims and all claims are sent to medical aids. Ensure medical aids receive all claims so that payment can be obtained with the next payment run of the medical aids. Ensure correct claims are marked as resolved and that claims not yet resolved are flagged for debt collection.
	Action maps: Collection stage: Information quality Compliance continuity stage: Updated information Confidentiality measures

Purpose of Claim Administration

GoodX provides practice management software and switching integrated directly into GoodX Software. This means you can manage everything from GoodX Software. 

• Cash flow is of vital importance to the health of a practice. One way of optimising the cash flow is to send your claim to the medical aid before the patient leaves the practice so that the cashier will know if the medical aid will settle the account in full.
  
•  If the medical aid rejects the claim, the cashier can inform the patient immediately and receive payment directly from the patient before they leave the practice.
• Claim administration assists the Practice so that the Debt Management run smoothly.
• We are referring to the 4 R’s - Reverse, Redo, Resend, Resolve.

GoodX Switch allows you to submit claims directly and in real-time into all major medical aid computer systems and to receive proof of submission and delivery of claims directly into GoodX. The switch establishes communication to and from medical aids so that the practice can adequately administrate their claims. 

The system should be kept up to date with all the available updates, for example:

• Medprax updates:
• Routing codes of the medical aids for successful EDI.
• Discontinued medical aid plans
• Changed medical aid plans
• New medical aid schemes and plans
• Changed medical aid administrators
• Billing rules for medication and materials
• Medical Aid Enablement:
• Enabling medical aids in the system, real-time and non-real-time medical aids, where the switch is real-time and will give an immediate response or where it is non-real-time where the response is not immediate.
  
• Remember to run the medical enablement to update the new and changed medical aid plans or schemes and check that all new medical aids are linked to the correct price lists.
• The update report can be checked to see if the medical aid update was done correctly.

Claim Administration is an ongoing process until the claim is resolved. The Claim Administration process will be divided into different segments that need to be followed. Each Segment will be discussed in the following chapter. The following diagram is the process flow that each claim must follow: 

Cashflow Management

Good collection processes are vital to practice management to ensure healthy cash flow. Inadequate cash flow is often the result of mistakes ending up in rejections, and when rejected claims are not quickly followed up, it results in claims that lapse.

The functions available in GoodX assist the practice to import information correctly into GoodX, resulting in spelling and typing mistakes being eliminated. The validation function confirms if patients are still members of medical aids and can confirm if funds are available for the claims to be paid.

The fact that most medical aid claims can be sent in real-time results in confirmation if claims are accepted for payment before a patient leaves the practice. Patients can then settle their accounts before leaving the practice.

GoodX provides a handy screen for the resolution of rejected claims. Claims can be corrected and resent to the medical aids without extra costs so that claims will not lapse. Electronic remittance advice results in an easy and speedy allocation of payments, ensuring that debtor data is up to date for quick debt collection.