2 min read

Update and Improve Medicare Claims Management

By Proclaim Partners on Thu, May 29, 2014 @ 08:00 AM

pcl_horn_playerI acknowledge that blogs are for the purpose of educating and earning your trust, but at times I think it’s alright to blow one’s own horn once in a while. After all no less a business guru than Kenneth H. Blanchard said, “If you don't blow your own horn, someone else will use it as a spittoon.” In the highly competitive world of claims clearinghouses, blowing our own horn is a must and doing it early is essential. Otherwise, the ensuing copycat cacophony will drown it out. So, here it is.

ProClaim Partners announces the release of its new integrated HETS/CLIP/DDE module as part of its automated claim processing clearinghouse software. For providers who bill Medicare this is a boon. It gives them access to Medicare eligibility and claims management tools through one portal. What is particularly noteworthy is that billers will be able to:

  • Browse claims data through the ProClaim Partners proprietary web user interface
  • Have a secure, high speed connection between the portal and the Centers for Medicare and Medicaid Services (CMS)
  • Enjoy an integrated implementation of the new HIPAA Eligibility Transaction System (HETS) for real-time eligibility determinations
  • Access Claims-in-Process (CLIP) which securely sweeps the CMS data during off hours for the latest claims activities.

The data seamlessly integrates into the ProClaim database and workflows. Together these functions will present the CMS data in a much more user-friendly, browser-based format than what billers have had through other tools. While CMS has recently delayed the sunset date for access to the older technology used for eligibility determination, the transition to HETS is still imminent. Why wait? With this new module providers don’t have to worry about a future sunset date.


For real-time Medicare eligibility determinations, ProClaim implements the new digital certificates (X.509), Simple Object Access Protocol (SOAP), and Multipurpose Internet Male Extension (MIME) standards within the ProClaim software service to provide web-based workflow and access to HETS. ProClaim makes instant programmatic determinations of eligibility against the CMS backend data store with minimum time and effort.

Claims in Process

The ProClaim Claims-in-Process (CLIP) function displays the current Medicare claims status, avoiding the need to navigate through the many legacy screens of the soon-to-be-phased-out eligibility inquiries into CWF using DDE for each individual claim. ProClaim’s CLIP accesses DDE during off hours to deliver programmed operator services. These services sweep the claims data off the DDE Mainframe and into the ProClaim database.

DDE Access

By design ProClaim minimizes DDE usage. However, under certain circumstances, claims administrators and billers may still need to access DDE. ProClaim provides a new and powerful DDE access solution as an integrated part of the software service. Now, providers have the choice of continuing to use 3rd party terminal emulation software for DDE access to the CMS Host or using the new ProClaim DDE access.

In summary, ProClaim Partners helps Long Term Care providers face a challenging environment converting claims to cash, especially when dealing with CMS/Medicare systems. In short, we’ve modernized and simplified the daily Medicare claims processing workload. The key benefits of using the system include:

  • Real time eligibility determination
  • Faster access to CWF data
  • Faster access to Claims in Process
  • Faster resolution of ADRs
  • Reduced training time for new claims administrators
  • Quicker collection of cash from claims

Tada! I have finished my horn solo. It’s nice to know that technology has caught up with the complex world of revenue cycle management.

Where are you in adopting new technologies to accelerate payments and improve cash flow?

Topics: automated claims management revenue cycle management web portal to manage claims HETS DDE CLIP
2 min read

Avoiding Unintentional Medicare and Medicaid Fraud

By Proclaim Partners on Wed, Jun 13, 2012 @ 08:00 AM

business_man_sad_face-resized-600Ignorance is no excuse. Over the last few months, like me, I’m sure you’ve seen headlines and read articles about the federal crackdown on Medicare and Medicaid fraud. Millions of dollars have been identified as fraudulently paid for services either not rendered or with limited justification. I acknowledge that there are unscrupulous practitioners and providers out there who should be identified, indicted, convicted, and sentenced to the fullest extent the law allows. However, while I don’t have the numbers, I wonder to what extent “fraud” was committed by those who unwittingly engage in poor billing practices, such as miscoding and/or absence of support documentation for procedures provided. Ignoring the old adage that if you didn’t document it, it didn’t happen, may put providers and practitioners at risk of investigation and indictment with all the attendant negative results, such as loss of reputation, decline in confidence, and possibly business failure.

If this falls within the reasonable realm of plausible possibility, I have to scratch my head and wonder why. Why place your business and your future at risk, when you don’t have to? Once again, IT can come to the rescue. Imagine the peace of mind you could have while reducing your DSO, assuming you are at risk not for lack of integrity, but credibility, if your organization had a billing and claims management system that would file clean claims each and every time.

Such an automated revenue cycle management system exists, specifically designed for long term care providers. Imagine a system comprised of a comprehensive and configurable user-friendly web portal to manage claims throughout the submission process, with functions for loading, reviewing, editing, and tracking claims online. With this portal, providers can fully leverage enterprise-level security and permissions with user-definable roles to satisfy their specific claims processing practices. As part of a complete health care transaction solution, providers can submit, monitor, edit claims, and review their claims on-line.

Key benefits of the ProClaim Partner’s application:

  • Increased revenue stream and reduced DSO through quick claims turn-around and real-time claims management reporting viewable through a user-defined digital dashboard
  • Smoother claims flow through direct connections with providers, trading partners, and value-added networks

  • Eliminating avoidable payment delays by increasing successful first-pass rates, tracking claims, and automatically checking claim status

  • Reduced transaction fees and paper handling costs by enabling direct connection with providers and payers

  • Decreased operations costs through automated handling of routine questions and documentation requests associated with eligibility, claims status, and referrals

  • Preserving investments in existing systems by offering an off-the-shelf claims management application that easily interfaces with existing adjudication, financial, and membership systems


  • Reduced risk through its robust user audit functionality

Providers would be well rewarded for looking into it. In times like these and under this “gotcha” environment of fraud crackdown, doing billing right certainly has its virtues. But a system is only as good as the workflow that leads to the filing of claims – preadmissions screening and documentation; admissions documentation; clinical documentation; therapy services documentation; proper coding; charges compiled; and claims created, scrubbed, triple checked, filed, and monitored. All are critical components of the workflow and are at risk of vital data and information leakage.

In the next blog, we’ll discuss some of these workflow components which are considered industry best practices.

Question: What solid claims management practices have you observed or implemented?

Topics: Medicare fraud Medicaid fraud automated revenue cycle management system revenue cycle management web portal to manage claims reducing DSO


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