By focusing on client needs first, VestaCare is able to identify process enhancements that can be tailored to the specific issues of each client, benefit plan and operating infrastructure. In most every case the VestaCare team seeks a common opportunity to help the client capture, leverage and preserve the human knowledge inherent in their current manual based operations. With VestaCare’s expert system wizards, the client’s know-how is “learned” rapidly and becomes an integral part of continuing automation. System integration between a primary claims or billing system can be achieved in hours versus weeks and expanded to include many secondary systems, databases, tables or external systems and sources. For each business application applied to Claims payment operations, the associated elements of VestaCare’s solution matrix are identified:
Payors: Healthcare Services
(“End-to-End Solutions for Perfecting Payment”)
| Enrollment & Premium Billing Data Management |
Claims Data Capture | Eligibility Test | PPO Routing & Repricing | Provider Match Logic | Auto-Claim Load & Auto Adjudication Optimization | Fraud & Out-of-Network Review | Automated Payment Management | |
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EDI knowledge of 834 format | Data Entry team | Plan member rules | EDI knowledge of 837 format | Customized rules for matching | Decision-making logic | Claim Adjustment rules | EDI knowledge of 835 format |
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Data Accuracy Management repository | 837 format data entry templates | Automated Smart Examiner | Transaction Router | Automated Smart Examiner | Automated Smart Examiner | Transaction Router | Transaction Router and Automated Payment tool |
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Payor’s Claim and Billing system | Payor’s Claim system | Payor’s Claim system | Payor’s Claim system | Payor’s Claim system | Payor’s Claim system | Payor’s Claim system | Payor’s Claim system |