MedReview Makes CoRe Improvements in Medical Claims Review Process

At the start of this year, NYCHSRO/MedReview went live with its newest technology for the performance of all types of future reviews, including DRGs and cost outliers. The Comprehensive Review Application, otherwise known as CoRe, is an intranet application accessed via web browser that enables reviewers to conduct claims audits with significantly greater speed and efficacy. As a simultaneous benefit, CoRe utilizes data analytics to continually refine and evolve our review process for increased efficiencies going forward.

MedReview’s CIO Pavan Devineni explains the technology.

“Data analytics filters out claims with potential errors—that is, potential savings for the clients to gain—and then presents the germane data on MedReview’s end user’s screen in a format that is easy for the eye to scan. CoRe is built in such a way that it uses the ‘real estate’ of the screen to increase efficiency of the review process. CoRe also selects the specific claims and the order they come up on a reviewer’s screen based on three factors: our receipt date of the claim, the client’s required date of delivery back, and the orderly, timely turnover of our review.

“Let’s say, for example, that two claims come to us on the same day, but one client expects their claim to be processed in 15 days while the other wants theirs back in 30 days. On Day 14, we want a reviewer to be looking at the 15-day claim, not spending time on the 30-day claim. CoRe sorts that out and auto-assigns the claim to an available and appropriate reviewer—a nurse, a doctor, etc.–and that’s what shows up timely in that person’s queue.

“This reduces the time required by our managers, who used to have to do all this manually,” the CIO explains. “In the meantime, the managers have a tracking queue to oversee what staff are doing, and when. There are also screens for generating letters from the claims, for tracking what is in the claim, and for quality checks—human eyes on the letter.”

Indeed, CoRe is the investment that keeps on giving. Its stored data allows MedReview to generate client reports as well as user reports that not only track how the system is working for individual staff but also track user performance in terms of the bottom line. As Devineni states, CoRe ultimately provides immediate answers to two key business questions: What amount of savings has a reviewer generated for the client, and how do we measure and track client savings?

Automation has been expanding throughout NYCHSRO/MedReview, from the mailroom to the scanning room and much more, so that the process of transferring, checking, tracking and distributing client files to appropriate staff happens “with no human eyes needed,” the CIO comments. “This has produced a savings of six work hours daily per staff person. In other words, 80 percent of an employee’s time is freed up to do other tasks.”

“What we have done with the scanning room we will eventually do for the auditing and coding processes,” states Devineni. “The goal,” he says in reference to the bottom line “is to reduce our overall time from ink to green.”