RCM

rcm ohum

The ohum RCM rules Engine forms the core of the entire business suite. The engine provides ultimate flexibility to define rules, conditions, and processes. that enables an almost flawless and human-effortless environment. The Rule engine takes the inputs from the facility, payer, patient, encounter, order/ bill (service), diagnosis, rate (charge), status, and a number of other data elements/ components and allows to set up complex rules.

  • Split Billing
  • Per Diem Rule (LTC)
  • DRG Rule (Addon Payment )
  • Per Diem Rule (DayCase)
  • DRG Rule (Outlier Calculation )
  • Per Diem Rule (Transfer case)
  • E&M Rule for New, Established, and UrgentCare Patient

Payer/ Contract Management

Payer contract management provides the ideal solution, automating any or all contracts accepted by the practitioner/ hospital and enabling real-time and automatic processing of eligibility checks during the ordering process itself.

With automated processes in place, the providers are able to assure themselves that any and all services provided to their patients are fully covered. This limits the need to manage denials, collections, and delays in receipts due to an improper contract management environment.

  • Contract period, Factors, DRG base value, and Billing Rule specific factor.
  • Handling of diagnosis-based, Provider-based, Service Category based contracts.
  • Managing specific requirements like deductibles on gross, deductibles on the net.
  • Defining patient-level policy for eligibility
  • Ability to assign multiple payers to a single patient
RCM

The allocation module will help managers to allocate the case to the Auditor and coder. Once the case is allocated the facility will not be able to change the activity this feature

  • Auditor Allocation
  • Coder Allocation
  • User wise allocation case status
  • Reallocate the case to other users.
  • Reverse the case to the facility level.

  • Easy to validate activity performed against Notes.
  • Automatic calculator E&M score.
  • Provision to raise the query department or consultant to get more details about the activity.
  • Users can change billing rules based on insurance approval.
  • Lab and Radiology activity will be enabled and a code and report are released, This helps coder for wrong reporting.

  • Verifying EID, insurance details, copayment, and authorization details.
  • Payer details correction can be updated at the auditor level instead of sending the case to the facility this will avoid delay in submission
  • Provision to raise the query department or consultant to get more details about the activity
  • Provision to recalculate the factor.

  • Query Category

e-Claims Processing

The claims processing procedure within the system is, by all counts, an exceptionally simplified process. Prior to finalization, claim audit processes are performed to ensure completeness and comprehensiveness. Editing claims is permitted with appropriate user authorization and should be completed in the originating system.

There is no need to have a clear definition of claims “period”. Accruals basis of revenue recognition is defaulted Claims can be in traditional manual form or through a paperless electronic environment (refer to Integration to eClaims).

  • Batch Claim generation and Submission
  • Provision to submit individual claims.
  • Third-party XML validation process.
  • Configure observation value
  • Attach the document
E claim processing