Next Generation Claim Review Engine

Studies have shown that up to 80% of medical claims contain errors and nearly 20% of claims are adjudicated incorrectly.

For many payors, it is difficult enough to just get the claim paid correctly, let alone to review the claim more deeply for billing and coding errors. Many code editing systems and bill review vendors are unable to look beyond rudimentary code edits and billing errors. At Nokomis Health, we are equipped to dig deeper, provide more comprehensive edits, and perform faster via our ClaimWiseTM review engine.

Innovation & Human Expertise

Our extensive industry knowledge and years of experience informed the need to develop our own proprietary claim review engine, ClaimWiseTM. Rather than working with an off the shelf system and trying to customize it to meet our clients’ needs, we built ClaimWiseTM from the ground up using APEX software and a team of expert developers. Housed in an Oracle database, ClaimWiseTM allows for rapid review of medical claims.

Claims are passed through hundreds of custom-built rules, millions of code edit combinations, and scores of reference tables. We know the importance of timely processing and with ClaimWiseTM we are equipped to return 97% of concurrent claims to our clients within one business day.

Nokomis Health ClaimFlow Chart
Nokomis Health ClaimWise Dial

Demand Based & Fully Customizable

ClaimWiseTM is fully customizable to our clients’ needs. We can turn rules and edits on or off for a particular client and we can customize our business rules to make claim edits more or less aggressive, depending on the client’s needs and requirements.

 

Seamless Integration & Hassle-Free Implementation

We know that our clients are busy, so we make the implementation process as painless as possible. We do the “heavy lifting” wherever we can, including adapting our file layouts to our clients’ format for seamless integration. We can accommodate both 837 and flat files. We lead our clients step-by-step throughout the entire process, resulting in a straightforward, transparent, hassle-free implementation.

ClaimWise Case Studies

A 44 year old female received radiation therapy for treatment of metastatic breast cancer. Nokomis Health obtained records to confirm the procedure codes that were billed and found numerous errors on the claims. Savings were $12,600 on total charges of $21,000.

A 27 year old male was treated in the emergency department for a laceration to his leg. The client was ready to pay the claim but we investigated the cause of the accident and found that the member was injured at his work site, so the claim was denied and referred to the workers comp carrier for payment. This resulted in savings of over $9,000 to the plan.

Nokomis Health’s ClaimWise rules engine identified a surgeon claim for a member who had no other claims for that date of service. We interviewed the patient and requested records and determined that the bill was sent in error. We denied the claim, resulting in savings of $8,200.

Request a Complimentary Analysis

Our non-intrusive claim review process is designed to save you the most money while ensuring the greatest accuracy. There is no need to conform to our system. We conform to you and your clients. Our proprietary engine rules were built around our knowledge, experience and the ever-evolving needs of our customers to ensure we find any and every savings opportunity.

Request an analysis today and see what ClaimWise can do for you.