Like most healthcare providers and payers, TPA organizations are leveraging the power of global outsourcing from experienced service providers that can perform key business processes, better, faster and cheaper.
At Grandeur Healthcare, our high performance approach to outsourcing brings improved methodologies, resilient, state-of-the-art IT infrastructures, accessible and knowledgeable personnel all through a world class global shared service center.
From the small local based TPA firms to the nation’s largest publically traded TPA organizations, Grandeur Healthcare Solutions provides a comprehensive array of workflow processes that deliver uncompromising value and continued cost savings.
Medical Bill Review
The work process involves verifying the Individual state specific bills following the state jurisdiction guidelines and indicates that the insurance should approve and pay those respective bills.
EDI – Electronic Data Interchange
This process involves verification and matching of the correct Individual and Group service provider information (like name, address, Tax ID, NPI, Taxonomy etc.) from Medical/Hospital bills and entering/matching the data in client application.
This process involves verification and matching of the correct provider information (like Tax ID, Pay or Received date, DOS, Total Charges, codes, etc.) in the electronic bill with the claim form (HICFA/UB 90) accessing client application.
UB-04 Hospital Bill Review
The process involves checking the provider details, procedures performed, Charges, DOS and other patient details.
CMS-1500 Bill Review
The process involves checking the provider details, services rendered, Charges, DOS and other patient details.
The refunds process requires calling the provider/facility and verifying the details of the overpayment made to the provider/facility. As next steps, it requires convincing the other party to pay back the amount that was overpaid in error.
Pharmacy Claims Intake
The work process involves checking if the prescribed medication(s) for Worker Compensation Beneficiaries are authorized by the adjustors and if not to create and complete the claims intake process for review and approval by assigned nurses (RN) on Client staff.
AR Collections Support/Old AR Analysis
AR Collections process is an attempt to translate the outstanding bills into payments to be received from the Adjusters or NCM’s (Nurse Case Managers).
As next steps the brief analysis of the claim and further course of action are recommended.
Physical Therapy Case Tracking
MSI team recommends appropriate visits after reviewing the case of injured worker and examine against the actual visits once discharged from Physical therapy.
Lock Box Posting Process
The process is to open each scan ID from the Lockbox, verify the check copy, amount and ensure the relevant Explanation of Reference (EOR) pages pertain to the respective check and they have to be attached to the correct account.
UM Intake Process
The work process involves processing requests received for UM (Utilization Management)/UR (Utilization Review) as Fax/emails, then complete the intake process for initiating review and approval by assigned nurses(RN).
W9 – Approval Process
The work process is identifying the Individual and/or Group Providers that are submitted as bills to Client and the Tax ID & Name submitted on the bill does not match the IRS (Internal Revenue Service) database.
Medical Management Error Transaction Report Management
The work process is to verify the transactions that come up in the payment error transaction report. The process involves rectifying why the payments are not posted in system and to take appropriate action so that the payments get posted.
Field Case Management Referrals Intake
FCM process is to verify/update the relevant information on the Field Case Management referral form and send it to concerned Adjuster/Case Manager/Area Manager/Sr. Nurse Reviewer for assignment and case set-up.
Provider Panel Verification
Panel Verification process helps to provide the injured workers with a comprehensive network listing of provider panels who accept Workers Compensation patients.
Wall Card Generation
Wall cards assist the employer/injured workers with a comprehensive network listing of provider panels who accept workers compensation patients. They include customized, classified and information regarding the nearest provider facility/specialty from proximity of the location (physical address) requested by an employer.