Multi-department team saves providers time by automating post-payment review process

Anytime we can automate a process at Palmetto GBA and maintain or improve accuracy, it’s a win. With the implementation of the Review Choice Demonstration, Palmetto GBA was tasked with generating post-payment review for all claims for providers who selected Choice 2 and for a sampling of claims for providers who selected Choice 4.

The post-payment review process involves looking over claims for potential fraud and originally was a manual task. Considering the high volume of claims that would need to be processed, a multi-department team was assembled to create a more automated system of reviewing claims.

This team developed a solution that minimizes the manual intervention needed in claim review and reduces the potential for errors. Expert Claims Processing System (ECPS) events were developed to route claims back to the appropriate areas in the Fiscal Intermediary Standard System (FISS) to allow the claim to pay. They also implemented a separate Medical Review Tracking System (MRTS) for all data collection and processing of Medical Review activities.

Without automation, this process would require 21 full-time employees to process post-payment review for the providers in Choice 2 and Choice 4. By reducing the need for manual intervention, this team is saving time for Palmetto GBA and our providers, which is worthy of earning the Division 28 Process Improvement of the Quarter.

Team Members

Harry Feliciano, Sheila Bell, Terri Bozard, Monique Brooks, Vanessa Carrero, Brooke Coker, Brian Corner, Aditya Deshmukh, Andrea Dixon, Jennifer Dowell, Cheryl Evans, Meg Grassi, Kim Hinson, Nazim Jeelani, Wendellyn Ladapo, Robert Lash, Amanda Moye, Jason Rhodes, Daliyl Skinner, Leigh Ann Tollison, Lendi Watkins, Amanda Wiseman, Laura Yochum

Dedication to improvement earns Medical Review Data Strategy Team divisional honor

The Medical Review Data Strategy Team has had to navigate a landscape of uncertainty this year, but they have risen to the challenges presented by the COVID-19 pandemic and adapted to rapid changes. They anticipated customer questions and offered solutions to issues providers might encounter.

The team reviewed all processes for improvement opportunities and was involved in the automation of the post-payment review process, reducing the need for manual intervention when reviewing claims from providers who selected certain choices in Review Choice Demonstration.

Members of the Medical Review Data Strategy Team accomplished all this while continuously motivating and uplifting each other. Their dedication to success and willingness to learn and adapt to new situations are a few of the reasons they have been named the Division 28 Team of the Quarter.

Team Members

Daliyl Skinner, Tim Oxley, Amy Bailey, Alesha Barr, Sheila Bell, Terri Bozard, Terri Brown, Cheryl Evans, Mary Evans, Chrystal Felder, Chris Hairston, Eileen Hamill, Janet Jackson, Denise Phillips, Molly Reynolds, Renee Robinson, John Rudolph, Shavonne Samuel, Jennifer Surak, Ayanna Taylor, Leslie Wells, Lauren Weston

Division 28 Coach of the Quarter works to empower others while providing excellent customer service

We are ALL about service at Palmetto GBA. That means it is the responsibility of all employees, no matter their role, to ensure our customers have an excellent experience. Clinical Reporting Supervisor Amanda Moye takes this to heart, which is one of the many reasons she has been named the Division 28 Coach of the Quarter.

Moye volunteered to help develop and present Review Choice Demonstration (RCD) training to the Provider Contact Center and Claims Operation Team, empowering members of those teams and elevating our customer experience. She also took on the challenge of developing policies and Fiscal Intermediary Standard System (FISS) actions for Outpatient Authorizations (OPA), making her vital to the success of RCD and OPA.

Moye prioritizes work assignments and delegates appropriate tasks to ensure all deadlines and metrics are met. She empowers her team to make decisions at the appropriate level and, as a great coach should, leads by example.

Associates of the Month

Jocelyn Williams-Phillips (July)

Jocelyn Williams-Phillips, Customer Service Advocate II, is always eager to assist her team members. She is well versed in the Center for Medicare and Medicaid (CMS) Health Integrated General Ledger Accounting System (HIGLAS) and share her knowledge readily.

Denise Phillips (August)

Denise Phillips, Medical Reviewer II, is dedicated to her team’s success and recently stepped up to take ownership of internal and external audits. She consistently meets deadlines and exceeds expectations all while motivating her teammates. She helped lead her team to 100% on their recent Jurisdiction M and Jurisdiction J Quality and Accountability Supplemental Payment (QASP) audits.

Alfreda Squire (September)

Alfreda Squire, Customer Service Advocate II, has been part of the Palmetto GBA family for more than 12 years and has experience with multiple lines of business. In her current role, she works diligently to provide excellent customer service. She also empowers her team members by sharing her knowledge in a thorough and patient manner.