Progress | Innovations

Strengthening Foundations

   

 

Refined Innovations

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Advanced Communication Engine (ACE)

As enhancement to ACE, our software that performs complex clinical claim editing within the EDI front-end process and before adjudication, Palmetto GBA developed a series of customized edits called eCompare. These provide real-time utilization alerts to providers whose billing pattern suggests potential over-utilization within a code set and their peer group.
 

ACE Administrative Impacts

32%

reduction in monthly average claims suspense

24.5%

reduction in monthly average denial related calls to the Provider Contact Center

17%

of rejected claims were not resubmitted

13%

decrease in the average monthly redetermination receipts

42%

of rejected claims were resubmitted with corrections

 
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Suite of eServices

Palmetto GBA is further developing its online provider service enhancements – feature-rich tools on our portal that allow the provider community to self-educate and compare themselves to peers. Critical in the process is utilizing our new eCompare messaging to drive providers to the specific tools on the portal. We’re working closely with CMS to define requirements and conduct focus groups, and have completed much of the technical work to integrate and optimally package the components to drive adoption and utilization by the provider community.

New tools include:

  • eCBR (Comparative Billing Reports): Allows provider access to a user interface to select and review data comparing their billing behavior to that of their peers. eCBR offers multiple graphic options for viewing the comparison data, allowing the providers to view their billing in relation to national, jurisdiction or state peers.
  • eUtilization: Allows providers to access and review data where their individual NPI has been listed as the ordering, referring or rendering provider on a claim. Physicians will be able to identify potential misuse of their NPI in these scenarios and will have tools to report these claims for further investigation.
  • eAudit: Gives providers insight into which claims are being audited by the A/B MAC. While denial and education letters originating from completed Prepay Medical Reviews are currently available, this feature will extend our claim status function and allow providers to view more robust audit information for their claims.
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    $1,123,380

    DMS Annualized Cost Savings

    Debt Management System (DMS)

    Palmetto GBA seeks to modernize Medicare debt management activities. The first phase of our initiative to accomplish this was the implementation of the Health Insurance General Ledger Accounting System (HIGLAS) Automator, a web- and server-based application processing routine and repeatable data entry requests and updating HIGLAS. In addition to an annualized cost savings of $1,123,380, the DMS application has realized increased workflow control, workload productivity tracking, and audit trail reporting.


     
     

    Enhanced Security Systems

    Since 2013, the Centers for Medicare & Medicaid Services (CMS) has increased its focus on systems security and heightened its number of security requirements by 50 percent. To meet – and exceed – these expectations, Palmetto GBA remains committed to improved overall system security.

    In the last year, we’ve made more than 25 enhancements to the Security Manager Application, which continues to automate security and compliance requirements and reviews. Continued automation has reduced audit issues, errors and costs associated with several controls.

    IP-360 System Security maintained an "A" rating for the past 39 consecutive months.

     
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    METRICS

    Performance excellence and near-flawless contract ratings drive scale.

    IMPACT

    Innovative solutions mean significant savings with tremendous effect.

    GROWTH

    Making strides forward through new business and expansion initiatives.

    INNOVATIONS