Rotating Webinar event topics:
“Auditing Benefit Configuration”
- Our research indicates that a typical member is impacted by 5 to 8 configuration changes each year
- 27% of Benefit Configuration errors result from incomplete or incorrect plan and product documentation
- With ever increasing levels of auto-adjudication, Configuration impacts everything – payment integrity, service levels and regulatory compliance
- An estimated 42% of Benefit Configuration errors result from inadequate testing
- Over 70% of Financial Claim Errors relate to incorrect Benefit or Pricing Configuration.
“Corrective Action Plans – When Process Workflows Really Matter”
- Corrective Action Plans vary based on their scope and purpose.
- A CAP plan model will be different based on the business need – a Regulated CAP, defined by some federal or state agency – a Business CAP, which may be defined by the company or leadership and, a Condition-specific CAP which may stem from internal audits and/or regressive testing protocols.
- On average, a CAP requires 41 different ‘touches’ from its identification through to remediation and final closure.
- Average turnaround time for CAP handling is 53 days from identification through to final closure.
“Audit Results – What’s Important to You?”
- Audit Purpose drives reporting results – specifically those differences that result between ‘Regulated vs. Non-Regulated’ audit segments
- On average, over 85% of audit staff are generally working on support of Regulated Audit tasks.
- Typically, the focus of Regulated Audits is aimed at providing accuracy and/or quality metrics for the organization
- Non-Regulated audits are generally more directed at specific opportunity or financial issues.
“What Are You Auditing and Why?”
- Rules for selection of the right sample are typically dictated by:
- Audit Scope and Purpose
- Regulated Audit Requirements
- Specific Company Policies
- Over 75% of clients incorporate some form of Stratification segment in their audit sampling protocol.
- Common ‘Gotcha’s that impact sampling and selection for audits include issues like:
- Adjusted Claims
- Denied Claims
- Population ‘Exclusions’
“Audit Selection – Random vs. Stratified Sampling – What’s the Impact?”
- Most Regulated Audits require some form of an ‘End-to-End’ audit protocol. Often the actual audit controls are split between departments. On average, 43% of companies have their Audit Team conduct the full scope of an end-to-end audit, while 22% of companies divide the individual audit steps into various departmental control.
- 3-7% of all Member and Provider calls to Customer Service identify new operational or system issues in Claims, Config and Enrollment processes.
- 68% of organizations have found that conducing routine structured audits overseeing their Appeal and Grievances had helped to build more effective workflow and compliance practices.
“Provider Contract Configuration Audits”
- Configuration is critical as ‘auto-adjudication’ rates manage over 80% of claims payments
- On average, each member is impacted by 5 to 8 Configuration Changes per year
- Typically, 100% of Configuration Changes are tested:
- 30% are tested by the Config department, pre-production
- 70% tested in production
- Additional 27% performed a Separate Claim Audit to validate Config settings / changes
- The average Configuration Analyst can complete 2 to 5 Contracts per Day.
“PrePayment Audits – There’s More than High Dollar Claims Swimming in This Pool!”
- Typically, 10% of Audited Claims are managed in a PrePayment protocol.
- On Average, 33% of Audited Dollars are reviewed in a PrePayment audit process.
- PrePayment audits are identifying an average of 2% Financial Error Rate on Claims in excess of $25,000
- PrePayment auditing requires a sensitive balance to manage overall clam timeliness.
- Average audit turnaround on PrePayment work is about 3 business days.
“Error Category Selections – Do You Really Know What’s in your Audit Errors?”
- As Much as 50% of Audit Errors are Categorized Incorrectly or Inconsistently by the Audit Staff.
- On Average of 25% of Audit Errors are Categorized Using a Code of ‘Other’ or Nondescript / Non-specific Categories – Not very helpful when trying to prepare remediation or results reporting.
- Incorrect Error Categorization can Lead to as much as 28% More Work – through increased appeals or delays in Recovery / Remediation.
“Appeals and Rebuttals – Preventing Error Runaround”
- On average, about 25% of claim audit errors are appealed (responder doesn’t agree with error)
- Over One Quarter of audit staff time is spent on managing Appeals and Rebuttals
- Appeals take between 35% to 55% more work to complete
- Nearly 20% of appeals stem from poor or incomplete audit error notes and documentation
- On average, 3% to 5% of claims posted are adjustments to an original claim.
- 70% of adjusted claims are positive – paying more to the provider.
- Nearly twice as many errors are found in adjusted claims than the original claim processed.
“Audit the Auditor”
- Only 50% of health plans perform ATA audits on a routine, scheduled basis.
- 25% to 50% of auditors select incorrect or inconsistent Error Categories for classification