Background
WINhealth Partners, the largest HMO in Wyoming needed to update its claims auditing system, and placed a high priority on finding software that was user-friendly. Beth Wasson, the company’s CEO had plenty of experience with complex systems that were underutilized by the staff, and she wanted to avoid a repeat performance.
Situation
Because of inefficiencies in the organization’s current system, WINhealth claims managers either had to review every claim manually, or risk paying out more money than was required.
“We needed some additional functionality. We were becoming large enough that we felt claims might be slipping through and that we could actually incur some savings if we had better audit functions.”
— Beth Wasson, CEO
WINhealth searched for a software solution that would not only be an effective claims auditing system, but also one that would remain invisible to claims processors. In this way, they could enter the data the same way as always without the extensive training needed for more cumbersome systems.
Solution
WINhealth turned to PCG Software for its financial recovery and claims adjudication system, Virtual Examiner®. Virtual Examiner handled the audit function of identifying erroneous and fraudulent claims while acting as an add-on to the existing EZ-CAP software the HMO was already using to process claims, calculate payments and issue checks.
Virtual Examiner was the ideal system for WINhealth because it cost much less than the big systems with similar functionality. By preserving the integrity of WINhealth’s data and catching erroneously billed codes, the HMO has saved thousands of dollars and recouped the cost of the software within the first few months of running weekly checks. |
