Until recently, traditional “pay and chase” post-payment claim auditing represented an outsized proportion of the tactics used by payers to ensure payment integrity. With advances in claims platforms, as well as selection and review turnaround times, payers are increasingly looking to implement solutions that prospectively identify and correct errors in the claim lifecycle.

Prepayment auditing analyzes claims during the adjudication flow, allowing payers to avoid -rather than recover- overpayments. This approach is particularly well-suited for high dollar/high risk claims, claims from non-participating providers, and to combat quick hit schemes, but can, and should be applied across all types of claims to maximize outcomes.

Beyond the convenience of more efficient flows, the benefits of prepayment auditing also include:

  • Balancing payment integrity programs to reduce excessive reliance on any one tactic
  • Lessening provider abrasion
  • Increasing savings on both medical and administrative costs.

Historically, prompt payment regulations posed significant barriers to prepayment auditing programs. Noncompliance with these rules results in costly interest and penalties. Also, given the number of nonaudit- related tasks that must be completed during claims adjudication, payers have an extremely limited window in which prepayment auditing can operate.

At SCIO®, we believe time constraints shouldn’t force payers to use a “watered-down” version of the latest auditing techniques and processes. Instead, our clients deserve to be on the cutting edge. To ensure this occurs, we’ve developed sophisticated analytics and a fully staffed team of clinical experts so we could apply the same rigor we’re known for in the post-payment space to prepayment claims auditing.

KEY BENEFITS

  • Prevent overpayments before they occur
  • Reduce excessive reliance on any one payment integrity tactic
  • Lessen provider abrasion
  • Increase savings on both medical and administrative costs

Interested in learning more about how you can avoid overpayments? Talk to one of SCIO’s industry experts today.

INCORPORATING PREPAYMENT AUDITING IN THE CLAIM LIFECYCLE

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THE SCIO DIFFERENCE

Precise Selection Reduces False Positives

Our efficient process begins with the selection of suspicious claims in three easy steps:

STEP1:

SCIO’s rules engine receives and scrubs a daily feed of adjudicated claim files.

STEP2:

Claims receive a billing or payment error risk score based a weighted application of: predictive member risk models, provider profiles, and custom-built queries matched to a payer’s specific policies.

STEP3:

Claims are selected for audit based on risk scores above a customizable threshold set by the client.

Selection and report of payment advice to clients is completed within 24 hours and clinical reviews are completed within 5 days.

Clinical Review Maximizes Overpayment Avoidance

To save time, many prepayment auditing solutions rely primarily on data mining to identify billing errors. This approach may reduce the risk of penalties, but it also limits the errors that can be found. SCIO’s program, however integrates robust analytics with clinical review to maximize overpayment identification.

SCIO’s audit team consists of over 150 accredited clinicians and pharmacists with an average of 15 years of experience. When they review a claim, they go beyond data mining and use the member’s medical record to determine whether clinical criteria supports a claim on four levels: documentation, level of care, site of service, and medical necessity. This ensures that all clinical aspects are accurate and the claim appropriately reflects them.

To move claims swiftly and efficiently through the process, our audit team leverages a workflow management application that automatically manages the flow, assigning claims to the most appropriate auditor and prioritizing workload based on the claim’s risk of error, expected overpayment, and prompt payment deadline. This, along with other process streamlining improvements, enables us to rapidly deliver a full clinical review of claims to clients within prompt payment timelines.

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