Health care spending in the United States reached $4.1 trillion in 2020, with annual spending projected at $6.2 trillion by 2028, according to the Centers for Medicare & Medicaid Services. The increases are due to the complexity of coverage but also to innovations in treatments and procedures.
Rising costs are a concern for both employers and employees, making it essential to ensure payment integrity for healthcare claims, according to Jessica Bemowskiresponsible for the integrity of payments for UMR.
“Payment Integrity puts policies and procedures in place to help control the total cost of care,” Bemowski says. “As we continue to see an increasing volume of claims and more complex procedures, it is important to ensure that there are end-to-end processes to review claims for fraud, waste, abuse and error.”
Errors and staff shortages
Errors are attracting more and more attention as third-party administrators (TPAs) like UMR seek to increase claims payment accuracy and save money for customers. Most of the errors found are unintentional, says Bemowski. On the contrary, the rapidly changing healthcare environment often makes it difficult for today’s workforce.
Staffing shortages facing the healthcare industry also extend to medical coders and billing staff. According to the US Bureau of Labor Statistics, the demand for medical records specialists and coders is expected to increase at an annual rate of 7% through 2031, which can make it difficult to recruit and retain qualified personnel. In a recent survey of CFOs by the Healthcare Financial Management Association, half said it is harder to find these types of skilled workers today.
Value of end-to-end payment integrity
To identify and reduce errors in claims payments, insurance companies and TPAs are leveraging technology and advanced analytics to drive accuracy, savings and provider education. Bemowski advises brokers to evaluate the payment integrity solutions in place – and the associated results – when making recommendations to clients.
“It’s important for a TPA to have a complete end-to-end payment integrity solution,” she says. “In the TPA world, we are responsible for the customer’s checkbook, so we want to be extra careful and treat their money like our own. With an end-to-end solution, you detect different things during different phases of a claim’s life. »
The first phase is pre-adjudication, a pre-claim review that applies coding logic to confirm the basics, such as whether the codes used in the claim include the appropriate number of units and can be billed together.
From there, claims go through a prepayment review that typically includes manual reviews by experts to determine medical necessity or identify potential fraud. Subrogation logic is also applied at the prepayment stage to determine if another party may be financially responsible for the injury or loss.
Thorough reviews generate tangible savings
At this point, standard payment integrity processes go through claims settlement, payment, and post-payment reviews. Bemowski recommends that end-to-end processes also include options for further assessment.
“UMR offers a program called Advanced Claim Review that uses specialized algorithms, artificial intelligence, and advanced detection analytics to target specific claims for additional review by experts, such as certified coders, registered nurses, and medical directors,” she explains. “These experts go beyond traditional review methods to request medical records, surgical notes and itemized bills to determine if what is being charged on the claim is in the medical record.”
Implemented in 2019 to review targeted physician surgical claims, UMR’s Advanced Claims Review Program saved 21 cents per member per month in 2020. Today, with an expanded reach that includes all physician and facility claims, savings exceed $1 per member per month.
“At the end of the day, you don’t want to find savings because that means there are errors in claims,” Bemowski says. “Our goal is to identify errors through technology and analytics so that we are able to target specific complaints and educate providers through these denials, so that complaints are billed appropriately to the future.”
Learn how UMR, the nation’s largest TPA, provides end-to-end payment integrity solutions that increase claims payment accuracy and reduce total costs.
Ann Clifford is a freelance writer who translates her background in financial services marketing into specialized content focused on employee benefits and small business topics.
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