Wiki Claims Scrubbing Programs--Payer Perspective

[ccaldewey]

Hi
We're looking at going with a new system, and I'm wondering if you could give me some feedback.
I work for an IPA and we're currently using an Ingenix (now OptumInsight) product called iCES to scrub claims that come through our system. It's alright, but due to some system upgrades and costs, we're exploring the idea of switching to another product.
Thanks
Carrie

 

[btadlock1]

Hi
We're looking at going with a new system, and I'm wondering if you could give me some feedback.
I work for an IPA and we're currently using an Ingenix (now OptumInsight) product called iCES to scrub claims that come through our system. It's alright, but due to some system upgrades and costs, we're exploring the idea of switching to another product.
Thanks
Carrie

Hi! I'm not a payor, but I've got some experience with iCES on the provider side. I can tell you that most of the time, it's relatively accurate, as far as most edits go (picks up bundling/NCCI, incorrect modifiers, incorrect diagnoses, etc.), and the payor that uses it is able to publish the rationale for the denial on the EOB; however, itt's not able to distinguish mid-level providers (NP's/PA's) from doctors on surgical CPT's, without the providers appending an AS or SA modifier, which is a headache. We frequently get incorrect denials stating that we need to add the modifier, and after MUCH discussion with provider relations, we've been told that it's needed to allow the system to assign the right fee schedule, and the only other way around it is to appeal with records and have the claims manually adjusted. (Kind of a nightmare when a large portion of our 120+ providers are mid-levels). You may want to ask about the capabilities on that issue before going for it. Hope that helps!