Achieve compliance
Health insurers deal with increasing regulatory requirements and related operational costs. Discover what OptumInsight innovation can do to improve compliance and efficiency.
Issues and challenges
ICD-10 and HIPAA 5010
As complicated and inconvenient as it may be, ensuring ICD-10 and HIPAA 5010 compliance is a necessity and an opportunity to improve business performance. The challenge lies in minimizing the time and cost of migrating to new standards while transforming organizational processes.
Regulatory reporting
The complexities of regulatory reporting must be well managed so that your organization can focus on core capabilities. The right data in the right format is required in order to generate accurate reports that meet state and federal regulatory requirements.
Medical loss ratio
To remain viable and competitive in the post-MLR marketplace, health plans need to develop their MLR strategy today. Plans can make well-informed decisions by examining the National Association of Insurance Commissioners (NAIC) model standards, interpreting how the standards will change business processes, and preparing for those changes efficiently and effectively.
Star ratings
Plans must work quickly to understand and respond to significant changes directed by the Centers for Medicare & Medicaid Services (CMS), including proposed changes to the Medicare Advantage and Medicare Prescription Drug benefit programs for the 2012 contract year, the quality bonus payment demonstration project, and revised quality star ratings.
Opportunities
Coding, Billing and Reimbursement
Effectively and accurately process ICD-9 and ICD-10 transactions according to pre-defined GEM standards. Quickly and easily transition to future coding classification systems with translation engines. Lay the operational groundwork for meaningful-use compliance.
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Electronic Data Interchange EDI
Ensure HIPAA 5010 and 4010A1 compliance with pre-production transaction testing and certification – and instream validation and routing solutions. Examine provider transactions in relation to all seven WEDI-SNIP types of testing, and validate more than 70 continually maintained code sets. Pre-qualify submitters against the latest versions of standards.
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Network Operations Efficiency
Mitigate compliance risk with end-to-end provider credentials verification. Spend less time tracking state regulations and accreditation requirements. Fulfill the NCQA requirement for facilities credentialing; achieve primary-source verification for hospitals, ambulatory surgical centers, home health agencies, and long-term care facilities.
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Payment Cycle Management
Expand your claims transaction system’s capabilities with valuable new utilities that reduce manual review and promote more consistently appropriate reimbursement with attendant cost savings. Develop fair and defensible reimbursement rates according to the rules of the Medicare PPS system.
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