Managed Care


 

The Managed Care department provides subject matter expertise for client hospitals for a variety of topics such as regulatory policies, contract management, and payer behavior. The team serves as the liaison between EnableComp and State Government and ensures compliance with reimbursement law.

Contract Management

  • Purchase and update all State and Federal Fee Schedules in Enforcer system
  • Model, load and maintain all client hospital PPO contracts in Enforcer system

Policy Advisement

  • Establish and maintain relationships with regulatory agencies, hospital associations, and trade groups in key states as well as large PPO Networks and payers that play significant roles with EnableComp’s client hospitals
  • Communicate and offer strategic oversight regarding legislative changes with material impact to EnableComp’s client hospitals
  • Oversee the EnableComp Thought Leadership Committee which seeks to educate and empower the hospital revenue cycle industry related to workers’ compensation

Clinical Review Team

  • Professional Nurse Review: Reviews claims and associated documents as well as the payer denial or EOB and generates acceptable responses along with recommended next steps for EC revenue specialists, payers and hospital clients
  • Certified Professional Coder (CPC): Provide coding support to EC Revenue Services and the clinical review team as well as hospital clients

PPO Network Consulting Product

  • Assist clients in the development of strategy for work comp managed care contracting
  • Analyze and communicate the impact of contracting decisions internally and externally
  • Create, produce and deliver detailed analytics, and reporting to clients as needed
  • Develop baselines and metrics to measure contracting performance and efficacy

Quality Assurance

  • Provide Quality Assurance on client reporting regarding reimbursement results
  • Manage the evaluation (scrubbing) of new client data files to identify contractual discounts, jurisdictional anomalies, and other false-positive claims