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How Workflow Guardrails Increase Claim Review Efficiency Through Custom Automation

ClaimLogiq makes claim reviews logical – from Payer to Payer, Provider to Provider, and review to review – by allowing unparalleled cross-collaboration in real time across work silos. TrueCost enables this real-time cross-collaboration through its seamless design, user-specific access levels, total transparency into every stage of the process, and options for real-time two-way communication within claims themselves.

That’s a lot of moving parts, I know. And when it comes to manual claim reviews, or using most claim review softwares, real-time cross-collaboration and multiple users having access to the review/platform risks further human error, messy chains of command, and drawn out turnaround times.

But before you get any heartburn from the thought of your workflows being unintentionally tampered with, know that TrueCost is uniquely positioned to protect your claim review processes – with Workflow Guardrails.

Workflow Guardrails in TrueCostOur clients choose TrueCost because of its potential for completely customizing each and every step throughout the life of a claim. But even with the unlimited potential for customization within TrueCost, there has to be a limit. So, in order to ensure that your platform accomplishes what you need it to with the desired workflows you have in place, we implement guardrails from the start that protect your reviews from issues that could arise at different steps of the workflow.

Not only can TrueCost administrators choose how claims of different sizes, scopes, and other factors should be routed by setting up custom claim review workflows, but they also set up the rules that those workflows have to follow in order to keep everything running as you’d intended. And, these workflows can be adjusted at any time – whether by account admins from the start, or enacted in real time by permitted TrueCost users.

This means that no matter who or when your claim reviews are handled, TrueCost makes sure reviews are done the way your Plan (and your Providers) want them to be every time.

Workflow Guardrails make sure that there are no exceptions when it comes to claim reviews getting routed properly.

 

Designing your custom review routes

Clients of ClaimLogiq can fully customize their experience reviewing claims within TrueCost – from the intake of claim data, to how provider relations are handled, to QA steps, and so on.

When you start your partnership with ClaimLogiq, we start your implementation process by ensuring we understand your Provider relationships and resulting workflow requirements like the back of our hand, so that we can build these custom routes out for you from the start.

From the beginning of our implementation process, we discuss the ways you need TrueCost to work for you, no matter how specific your needs are. We discuss the different ways we could adjust TrueCost to fully suit these needs, and how these options would play out, from the get-go.

Payers are in complete control of their review workflows

We work with you to determine what your claim review workflows should look like in order to hit all of the check marks when it comes to your preferred review workflow.

…And then, we think of everything that could go wrong. (Backwards, I know.)

 

Reverse engineering workflow consequences from the start

No matter who's reviewing your claims, your Admin determines where the claim goes next

What if the wrong person were to mark the review complete after unknowingly skipping a step in the process? What if one reviewer knows about a key anomaly that makes this claim different from the rest, but doesn’t think to pass that along to the rest of the chain of command? What if a claim has to be sent back to a specific reviewer, but accidentally goes through the entire workflow for a second time, wasting precious reviewer time (and sanity)?

Phew. Now that we’ve got that list of nightmare scenarios, we can reverse engineer some things.

 

For starters…

  • Maybe, certain reviewers can only move claims forward in the process.
  • Perhaps, reviewers can’t move a claim anywhere but its intended destination.
  • If a specific scenario is present in a claim, maybe this claim uniquely gets sent to a single reviewer who handles all special cases.
  • Or, if a claim absolutely has to be sent back to the beginning of its workflow for another round of edits, maybe it’s started on a new separate workflow instead, where it skips past all the steps already completed once the issue is resolved.

By designing with logic in mind from the start, your Plan can fully trust that collaborating on claim reviews within TrueCost will increase efficiency – never hinder it.

 

Give controlled access to reviewers

Our cloud-based software is designed for an intuitive user experience that makes the claim review workflow seamless, no matter how tech-savvy your team members are, or how many eyes you’d like your claim to be seen by before being completed. Because of this, it makes it easy to get every required member of your team set up as a user in TrueCost in order for them to access claims.

But with the option for so many hands to touch a claim – both at different stages in the process, and in real-time, if needed – how do we ensure that there are no hiccups along the way? How do we ensure that clients’ custom workflows, rules, and edits always serve the client’s best interests?

Controlled User Access

User-level access and workflow guardrails are intertwined. Workflow guardrails largely center around user permissions and who should have which abilities when it comes to determining where a claim goes next.

Because user access levels are specified during implementation (and at any point throughout your partnership with ClaimLogiq), the right roles can make the right determinations without being bogged down by delays. Each user has their specified piece of the puzzle and knows where each claim is to go next.

But, sometimes things don’t go as expected. Maybe there’s a specific procedure code on a claim that prompts further review by a specialized reviewer, or requires more information from further medical records.

Your Plan can determine the intended workflow, while also giving users the freedom to reroute that workflow as needed when it makes sense. And, still, workflow guardrails are in place so that this happens in the most efficient way possible, by making sure that users can only adjust workflows to the extent that their permissions allow.

Payers can make reviews as efficient as possible by eliminating the option for claims to go anywhere but their intended workflow.

Workflow guardrails ensure that the ability to re-route claims is locked down with controlled access and controlled modifications to workflows for maximum efficiency.

 

TrueCost Admins can update Workflow Guardrails at any time, without limits

While user-level permissions are in place to protect reviewers from unknowingly bogging down the workflow parameters set in place by account admins, the account admins themselves can make changes across the board in real-time as changes become necessary.

Should a new industry law become relevant to your reviews, or should your team come up with a more efficient process for collaborating on claims in order to uncover more potential savings on claims, you can make changes over time. the admin has the freedom to update or change these at any time, so that you’re able to adjust while staying on top of industry trends or updated Plan/Provider requirements.

Admin Change Controls

The TrueCost admin has real-time change controls to send claims from one reviewer to another, skip over specified workflow rules, or change the workflow entirely. They can update other users’ permissions or revoke them as needed, instantly updating the corresponding guardrails put in place.

It’s important that our clients can adjust things as needed. After all, what’s the point of a completely customizable platform if it only hinders you months later?

 

Utilize Workflow Guardrails in TrueCost to maximize efficiency on customized claim reviews

You can rest assured that no matter what real-time edits you or your chosen reviewers make with the freedom our platform grants you, you’re protected by the logic we’ve built in.

Workflow Guardrails in TrueCostAutomation is key to increase efficiency and reduce human errors and maximize TATS and savings, greater ROI and faster speed to payments.

But real-time accessibility shouldn’t jeopardize those standards you’ve put in place. And you shouldn’t have to choose one or the other.

Workflow guardrails protect Payers’ specific claim review environments from negative changes, so that you can customize AND optimize at the same time.

Learn more about TrueCost

Rebecca L. Price
Rebecca L. Price
As the Vice President of Brand Marketing and Communications, Rebecca leads the strategy for ClaimLogiq communications and engages with ClaimLogiq's audience through social media and other digital platforms. Rebecca has decades of experience writing about software and technology and has produced informative healthcare innovation materials in the form of white papers, print, and video content. Rebecca studied Integrated Strategic Communications and holds a bachelor’s degree from the University of Kentucky.

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