SCIO Health Analytics® Launches Expanded Prepayment AuditingView as PDF
Prospective and swift claim auditing integrates predictive models with provider profiling to avoid overpayments
WEST HARTFORD, Conn. – June 8, 2017 – To help payers to conduct audits earlier in the claim lifecycle, SCIO Health Analytics® today announced the expansion of its prepayment auditing service for diagnosis-related group (DRG) and DRG Short Stay audit concepts. Prepayment auditing helps payers avoid, instead of recover, costly overpayments, streamline payment integrity programs, and generate increased savings on both medical and administrative costs.
“Traditional post-payment – or pay and chase – audit tactics can be costly, ineffective, and lead to unproductive and unnecessary conflicts with providers,“ said Eileen Cianciolo, chief product officer with SCIO Health Analytics®. “Health plans must pay provider claims within a specific timeframe or risk accruing late claim payments and penalties. SCIO’s prepayment analytics reduces payers’ reliance on post-pay tactics, making it ideal for claims from non-participating providers and to combat quick hit schemes.”
SCIO’s prepayment auditing service uniquely combines sophisticated analytics with unmatched clinical expertise to efficiently select and thoroughly review claims. A rules engine analyzes a daily feed of adjudicated claim files to score each claim’s risk of payment error based on a weighted assessment of member risk scores, historical claims, provider profiles and known client system limitations. Claims with scores that cross a client-determined threshold are loaded into the SCIOMine workflow management application and are automatically assigned to an auditing resource, prioritized based on the prompt payment guidelines associated with each individual claim. SCIO’s accredited clinicians then use the member’s medical record to determine whether clinical criteria supports a claim on up to four levels: documentation, level of care, site of service, and medical necessity.
This approach ensures that audits uncover the maximum amount of billing or payment inaccuracies and are completed within prompt payment timelines.
“Our sophisticated analytics rapidly select and process claims for further analysis by our auditors,” said Lalithya Yerramilli, SCIO’s vice president of analytics. “In addition to quicker turnaround times, this use of integrated predictive models and provider profiling also ensures precise claim selection, which reduces provider abrasion by minimizing the chance of auditing claims with false positive findings.”
Also contained in the service is robust reporting including daily payment advice and operation dashboards and monthly key performance indicator and program scorecards.
To learn more about SCIO’s prepayment auditing service, visit our website.
SCIO Health Analytics Contact:
Michele Norton, M.S., R.N.
Senior Vice President Marketing