Payment integrity – a conundrum in health plan administration. With over 20 years’ experience, we’re keenly aware of how difficult this goal is to visualize, let alone achieve. At the foundation of claims processing are a host of systems, applications, people and services which drive payment. These underlying factors change daily as new products, pricing arrangements, systems, benefits and regulatory requirements are introduced. How one change may impact all the inter-related systems and functions and downstream payment issuance is more like a game of whack-a-mole to oversee.
We think of payment integrity in healthcare claims as three things:
It doesn’t seem that anyone has fully ‘figured out’ how to tackle payment integrity. Indeed, we are earnestly working toward that broader objective.
Our other product pages outline specific products we offer which provide world class solutions for select segments of the payment integrity universe. Beyond those formal offerings, we are working on pilot or beta products and services to further explore ways to better address the payment integrity challenge. Examples of items we have in development or pilot include:
Prepay Cost Containment
Datamethod has developed prepay rules and workflow tools to support prepay audit of claims (cost containment). These rules have been used to save over $50 M in prepay dollars in 2017.
Claim Risk Index
Datamethod has developed a rule engine and schema to support indexing claims to identify those claims that represent the most significant payment risk.
Provider Appeal and Member Correspondence Audits
Datamethod is developing features and workflows to manage provider appeal or member correspondence audits. Many provider and member calls are actually related to claims payment – another source payment accuracy issues and recovery opportunities.
Datamethod is developing population rules to identify affected claims (claims impacted by payment errors) and workflow tools to support recovering those dollars.
Reporting and Analytics Tools
Datamethod has developed numerous reporting and analytics tools including: (1) a stand- alone portal to report administrative claim metrics (adjustments, AA rate, turnaround, employer PGs,…), (2) a stand- alone portal to report audit metrics, (3) a database repository designed to enable error and audited claim analytics for customers.