Background
Memorial Healthcare System has provided healthcare services to South Florida residents for more than 50 years. Its flagship facility, Memorial Regional Hospital, located in Hollywood, Fla., is one of the largest hospitals in the state.

With patient volumes rising, the health system found itself challenged to keep up with a high number of changes in coding, coverage, and payer guidelines to follow.

Situation
The health system's nine-person claims department performed code auditing for nearly 35,000 covered lives via a paper-based method. Quality control thus became the responsibility of each claims specialist while entering information into the system.

The paper-based process often revealed limitations when a claims history review was requested. There was no easy way for specialists to decide, for example, whether the file they were looking at was a duplicate or whether the patient was eligible or insured. Billing matters were likewise impossible to track accurately, particularly with regard to accidentally overpaid or duplicate bills.

Solution
Memorial Healthcare decided to take a proactive approach to ensure that its physicians were being reimbursed fairly, while opening the door to potential cost savings.

The health system selected PCG Software's Virtual Examiner to detect not only improper claims but also coding errors and duplicate payments. As a Medicare-compliant solution, the system interacts seamlessly with the organization's current vendor contracts.

"Our claims department was up and comfortable with the system in no time," says Tracy Harswick, director of claims and decision support. "The software integrated with our processes far better than we had anticipated, and our claims specialists were immediately freed up from the chore of manual reentry of data fields and claims histories." 

Virtual Examiner monitors internal claims processes to detect abusive billing patterns while identifying areas to reduce payments for improper or erroneous coding. The system identifies unclean claims to maximize federal recovery efforts and conserve premium dollars. It complies with all Medicare and CCI edit guidelines and is scalable to comply with frequent business and legislative changes.