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Development of an Enhanced Revenue Cycle Management System for Streamlined Medical Billing and Insurance Claims Processing
  1. case
  2. Development of an Enhanced Revenue Cycle Management System for Streamlined Medical Billing and Insurance Claims Processing

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Development of an Enhanced Revenue Cycle Management System for Streamlined Medical Billing and Insurance Claims Processing

effectivesoft.com
Medical
Healthcare Technology

Challenges in Medical Billing and Insurance Claim Processing

The client lacked a comprehensive system for claim processing and billing, leading to fragmented or incomplete patient data, frequent claim denials, delayed reimbursements, and administrative inefficiencies. These issues hindered timely payments and compliance with regulatory standards.

About the Client

A private company providing Personal Emergency Response Systems (PERS) to enable at-risk patients to access immediate medical assistance while remaining at home, aiming to reduce hospital readmissions and improve health outcomes.

Key Objectives for Revenue Cycle Management System Development

  • Streamline medical billing and insurance claim submission processes
  • Ensure compliance with healthcare data security and regulatory standards
  • Integrate modules for both referring agencies and private customers
  • Reduce claim denials through automated validation and eligibility checks
  • Enable efficient payment posting and denial management workflows

Core System Functionalities and Key Features

  • Preauthorization and eligibility checks with automated data validation
  • Payer-specific claim submission with clearinghouse integration (e.g., EZClaim)
  • Automated payment posting and reconciliation with overpayment/partial payment handling
  • Denial management system for analyzing, correcting, and resubmitting denied claims
  • Secure customer portal with two-factor authentication (via Vonage SMS API)
  • Payment processing integration (Authorize.Net) for credit card/bank transactions
  • Invoice dispute resolution and refund management for private customers

Technology Stack and Development Tools

C#
JavaScript
TypeScript
SQL
.NET Core
ASP.NET MVC
jQuery
Twitter Bootstrap
OAuth 2.0
RESTful APIs

Third-Party System Integrations

  • QuickBooks Online (QBO)
  • EZClaim
  • WayStar
  • Change Healthcare
  • Authorize.Net
  • Bill.com
  • NaviNet
  • Google Maps
  • Bing Maps
  • Microsoft Dynamics CRM SDK

Non-Functional Requirements

  • HIPAA and GDPR compliance for data privacy
  • High scalability to handle increasing claim volumes
  • Real-time processing performance for eligibility checks
  • Secure authentication and role-based access control
  • User-friendly interfaces for both agency and customer portals

Expected Business Impact of the RCM System Implementation

The new system will optimize revenue cycle efficiency by reducing claim denials, accelerating reimbursements, and minimizing manual administrative tasks. It will enhance data accuracy, ensure compliance with regulatory standards, and improve financial outcomes for both MedScope and its customers. Continuous support and integrations will future-proof the solution against evolving healthcare industry demands.

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