Problem Statement

After a claim is billed, the payer confirms receipt but staff still have to understand the payment status with the payer. To do this, staff log into each payer portal and look up each claim to see whether it is paid, pending, or denied. Then they write the status and notes back on the account. This is high-volume, repetitive lookup work. The longer an account goes without follow-up, the more likely it ages past 90 days or a timely-filing limit, putting collectible dollars at risk. Capturing statuses quickly also lets accounts receivable be segmented and routed correctly. Denials go to the right work queue, and paid claims close out instead of sitting in the follow-up pile. Pending claims can simply be left to re-check on the next run, sparing staff a portal visit until the claim resolves or stalls (3 runs or 14 business days). Medicare statuses are checked in the MAC portals, including DDE and regional contractors such as Noridian, First Coast, and Palmetto, where return-to-provider and finalized claims have to be identified and fed back to the EMR.

Automation Solution

This automation accesses the regional Medicare portal to retrieve claim statuses and updates the EMR with statuses and notes to trigger the appropriate follow-up actions.