Health plans are moving away from the retrospective pay-and-chase model and adopting an enterprise-wide approach to payment integrity. The focus is now on advanced analysis, early detection, and rapid mitigation to lower incidences of fraud, waste and abuse. Here is a look at seven best practices that can help you effectively address payment integrity issues stemming from intentional and unintentional reasons.
1. Implementing a cycle of self-assessment – Payment integrity covers a wide spectrum fraud, eligibility fraud, subrogation and form-filling errors. Self-assessment will help you spot gaps in claims processing. You can benchmark against industry best practices to optimize your claims processing environment.
2. Set up a framework for prepayment review – Reviewing claims prior to payment allows an initial determination. It flags off inaccuracies and enhances the efficiency of claims processing activities. Some ways in which you can optimize your claims processing environment include:
- Deploying a claims edit system that checks claims for omissions, errors and questionable coding relationships. The claims edit system should be able to perform auditing logic that automates new policies and creates new rules without intervention from the vendor.
- Up to 7 percent of healthcare claims are inaccurately paid. A proactive, aggressive prepayment approach is effective in detecting fraud, abuse and waste. This approach should be based on financial analysis, medical analysis, and uncovering changes in behavior. The insights gained from a claims review will help in refining and optimizing your fraud detection system.
- Medicare’s Prospective Payment System splits the liability arising from claims between you and your provider network. By applying the same approach to commercial, Medicare Advantage and Medicaid lines of business, you can manage risk, make reimbursement calculations, and brainstorm the impact of reimbursement strategies before implementation.
- Implement coordination of benefits, which allows you to determine respective members’ payment responsibilities. This includes reviewing how a certain plan will contribute when the member is covered by more than one plan.
3.Invest in claims analytics software – Sophisticated claims analytics software can analyze data across all stages of the claims cycle for informed decision-making. A SaaS solution can help you manage costs more flexibly and free up your team to work on more profit-oriented tasks.
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The author credits the material in this article to whitepaper from Optum. Download the “Maximize savings with an enterprise payment integrity strategy” whitepaper. |
4. Emphasize integrated analytics to identify the most problematic processing errors – There is a distinct benefit to leveraging both provider-centric and claim-centric analytics. Provider-centric analytics will look at historic data to filter providers with a track record of fraud, abuse and waste. Claim-centric analytics identifies patterns associated with overpayments.
With both of these analytics platforms, you may be able to identify a higher number of overpayments and inaccurate claims. You’re also in a better position to single out those claims that deliver the highest potential for savings.
5. Utilize an electronic payment system – An electronic payment system will reduce paperwork and associated costs. It can also unify the payment stream, making administration less complex and more easily trackable.
6. Collaborate with partners who support your prepayment review goals – Support from vendor partners who are as proactive as you in detecting inaccuracies in the prepayment stage is crucial. The shared goal should be to prevent payment integrity blunders by nipping them in the bud.
7. Partner with a single multi-tasking payment integrity vendor – Consider working with a vendor with best-of-breed capabilities, and who can handle multiple payment integrity practices. You will be saving on the costs of multi-vendor support while also receiving a consolidated view of your payment-processing environment.
Effective data management and high-end analytics is critical in reducing error rate, trimming waste, and staying competitive. Establish payment integrity best practices at the earliest to see tangible bottom line benefits.
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The author credits the material in this article to whitepaper from Optum. Download the “Maximize savings with an enterprise payment integrity strategy” whitepaper. |
** The views expressed in this article are of the author and do not reflect the views of DistilNFO or Optum.
Source: Optum