Payment Integrity

overview

Payment Integrity

Our Payment Integrity services help you eliminate the pay and chase model and shift to the detection and identification of improper billing in prepayment environment. We provide this service on a contingency basis which eliminates the financial risk for our clients and help you pay for what is right. We combine the technology, analytics, and industry domain knowledge to identify improper payment trends as soon as they appear. Our experts’ partner with clients to provide a roadmap that adopts a hybrid method of claims and medical record review process. Our focus of profit discovery is improving our clients’ financial performance via a combination of audit, analytics, and advisory services.

Our Payment Integrity Suite Includes:

PRE-PAYMENT

Line by line coding error results, Provider wise Audit Findings, Financial Impacts, Higher cost savings, Effective resource utilization

POST-PAYMENT

Complex overpayments that adjudication systems often miss, Identify where to focus the internal audit efforts, Recovery performance by recovery area, High -value and High-risk patterns

FRAUD, WASTE & ABUSE (FWA)

Clustering of the abnormal group of claims relevant to a potential abuse models, Better leads for auditors, Utilization review, Cost savings, Quality of care

CONTINUOUS & ROUTINE MONITORING

Complex overpayments that adjudication systems often miss, Identify where to focus the internal audit efforts, Recovery performance by recovery area, High -value and High-risk patterns

Case Study

Situation: For a mid-size health system, Jade started with initial screening – random sampling audit using general payment integrity categories with the goal to understand the payment, coding and documentation issues missed out by the payer in the internal audits.

  • Jade targeted to capture non-compliant coding practices, medical necessity issues, improper billing of consultation services, double billing of Evaluation and Management Services and improper payments that leads to revenue leakage.
  • The inquiry on claims review was made with the selected batches of anonymized medical records and the respective claim forms
  • Jade sampled 40% of the encounters for the pilot study that included Outpatient, Inpatient encounters and same day admit discharge
  • For each medical claim audit, or in each recurring audit cycle, we apply Statistical Analysis to stratify volume by place of service, by facility, by type of claim and by other natural common dimensions as dictated by the data
  • Focused audit was carried out to flag unbundling and billing of excessive units using CMS NCCI and MUE edits.
  • Potential improper payment identified was approximately 5%
  • The audit process and comprehensive reporting capabilities uncovered the root causes and identified the “red flags” or high-risk behaviors that reflect potentially inappropriate billing or fraudulent claims.
  • After the initial screening, the claims department entrusted Jade for continuous support and to conduct the post-payment recovery audit
  • The focused audits targeted on high dollar charts such as critical care claims, level-5 Evaluation and Management visits, unbundling issues and potential areas that requires additional documentation and coding education
  • Recurring audit cycles were done every 45 days in batches with educational sessions conducted for the claims audit team of the payers, after completion of each batch.
  • Jade team reported an average of 18% payment adjustment after the audit of 6 batches.