Navigating the Managed Care Landscape
The Office of Managed Care (OMC) plays a pivotal role in ensuring that the ten hospitals and over forty affiliated clinical care facilities across Johns Hopkins Medicine (JHM) receive payment from insurers (third-party payors) for healthcare services provided; payments that account for over $5 billion in annual revenue. One of the OMC’s key responsibilities is providing relevant payor and regulatory education, and health plan information to billing specialists across all JHM entities.
These billing specialists verify that patients’ procedures are covered by their respective health insurance plan, bill health insurance providers for medical services provided, and ensure that all applicable laws and regulations are followed in the process. The OMC provides the information, resources and support billing staff need to make the accurate processing of medical claims possible.
Providing hundreds of billing specialists across Johns Hopkins with timely and accurate information on the 50+ health insurance plans accepted by Johns Hopkins as well as on the evolving landscape of health insurance regulations was a struggle. Insurance providers regularly changed rules around procedures covered and verification/approval requirements, making it very difficult for billing staff to keep up with current rules and requirements. These issues had significant revenue implications if Johns Hopkins performed services that an insurance provider would not cover.
A legacy intranet platform existed that provided documentation on each health insurance provider, their rules, and verification and billing procedures. But this intranet was just a collection of PDF documents from insurance providers, each in a different format, some out of date, and all difficult to search, use and manage. SAI Digital set about to solve the problem by developing an easy-to-use web-based application to manage and distribute detailed health insurance payor information.