Through automation of benefit management, we make a huge difference for our customers. Our sister company Wonderbox Technologies, developer of our software platform called the Enterprise System, is recognized as one of the leading technology companies in the healthcare administration space. Using this innovative software, we can configure benefit plans, reimbursement rules, business rules, claim edits and payment rules to ensure that claims are handled properly with almost no manual intervention. We are also experts at configuring data interfaces to automate the data transfer between our system and your administrative systems, reporting systems, clearinghouses and any government systems.
The Executive Dashboard features detailed statistics and comparisons in primary areas of benefit management, including volume and timeliness of claim payments, and performance metrics. Clients can also use it to monitor call center statistics, including metrics for call volume, primary call reasons, and first call resolution. Featuring real-time data available anytime through a web-based portal the Executive Dashboard gives clients the advantage of unlimited transparency into their healthcare program. Drop-down filter criteria are used to dynamically adjust the report to specific clients, regions, dates, etc.
Vestica Healthcare maintains a comprehensive set of predefined medical edits, and subscribes to regular updates for Medicare-specific edits, such as the National Correct Coding Initiative (NCCI) Edits. Any edit can be turned on or off, corresponding exception messages can be customized, and client-defined edits and exception messages can be incorporated into claims processing steps through the user interface without requiring a programming change. Services that trigger an exception are reviewed to determine whether any action is warranted, such as reporting potential fraud or abuse to the client. Our customizable edits and exception processing capabilities can automatically identify inappropriate services before claims are paid, which allows us to reduce medical benefit costs.
Custom Web Portals
Our custom web portals decrease administrative cost and improve access to reliable, real-time information for our clients, their members and their providers. From electronic submission of claims to on demand reporting and review of claim status or customer service events, our portals enable self-service capabilities for every step of the claims administration process. Each portal is designed to make accomplishing specific tasks straightforward and stress-free.
Our Branded Client Web Portal is the gateway to powerful oversight and management tools:
- Launch the Customer Service Module (CSM) to track and resolve customer inquiries
- Launch the Executive Dashboard to monitor key business statistics
Our Branded Provider Web Portal is a powerful online tool that promotes improved provider servicing and efficient claims processing through:
- Claim management
- Eligibility status inquiries
- Benefit limitations
- Data entry shortcuts
- Report, document and file manipulation
Our Branded Member Web Portal offers unparalleled self-service options for members including the ability to locate or change a provider, verify eligibility, review claim status and details, and even order or retrieve a temporary ID card.
Flexible Authorization Requirements
With flexible authorization requirements and a simple submittal process, we can make it easier to control benefit and administration costs. We offer the ability to automatically link claims to specific pre-authorized services, and our claim processing engine can consume prior authorizations and service items automatically. Vestica Healthcare can tailor the rules for matching claims to pre-authorized services based on each client’s requirements. When our system cannot match a service that requires pre-authorization against an open authorization, an exception can be recorded on the service. These exceptions can be reviewed and resolved before the claim is adjudicated.
Customer Service Module
With this module, Vestica Healthcare customer service representatives (CSRs) have all the tools needed to resolve members’ and providers’ questions during the initial communication with our contact center. CSRs have instant access to a host of customer service tools, including claim history, authorization history, eligibility history and office reference manuals. On the rare occasions when a second connection is required, CSRs can track and complete the follow up.
The module also provides complete, real-time transparency for our clients into all CSR team member interactions with members and providers as well as historical tracking of each point of contact. We maintain a comprehensive history for every member and provider in our system, including audio transcripts of all communications.
Vestica Healthcare and the SKYGEN USA family of benefit management companies have performed numerous implementations for complex programs with member populations of all sizes. Our technical team has extensive experience handling a variety of integrations and data exchanges with existing systems and services. Our implementation approach begins with customization of the project plan to meet each client’s specific requirements and timelines. We handle change management and ongoing risk assessment and management through frequent, ongoing communication. Our goal is to minimize surprises and address possible risk factors immediately, before small questions ever have a chance to become big issues.