Even in the electronic age where large amounts of data are capable of being transferred, collected, crunched, and processed, paying claims accurately is still a problem for most carriers. And it is the client who usually pays for this ineffectiveness. Companies desiring to track correctness of payment or wanting to recoup losses for incorrect payments have been relegated to costly and time consuming file audits. Using our partner Artemetrx, we can analyze all claims payments to identify duplicate claims, overpayments and ineligible payments. Claims payment monitoring, along with explicit contracting/performance standards around claims payment, can help the employer keep ahead of claims payment errors through routine checks on payment accuracy.
Claims Payment Monitoring
Employers wishing to establish a system by which they can recoup losses, or withhold money due to vendors, can take advantage of the Automated Claims Audit program to analyze the correctness of claims payment on an “on-going” basis. Monitoring analyses can be scheduled to run annually, quarterly or monthly. If you are going through a renewal or re-contracting process you should consider implementing this program to track correctness of payment. Of course, as part of our service to you, HC21 and our partner Artemetrx, can help you negotiate the necessary conditions with your TPA that allow you to collect for incorrect payment, and then monitor payment correctness through the Automated Claims Audit Program.
Claims Payment “One-Time” Analysis
Members interested in testing a vendor’s payment capabilities as well as testing a vendor’s willingness to improve their capabilities can use the Automated Claims Audit program on a limited basis to identify “areas of concern” for the vendor to address. A one-time data run can establish in detail areas where the vendor may need to improve; for example, duplicate claims, payment for ineligible members, payments greater than amounts physician billed, etc. The information discovered through this type of analysis can be very important in determining performance standards, and/or as part of an initial contracting evaluation.
For more information contact:
Jeff Townsend, Director of Research, HC21
