Unfortunately, healthcare transactions are not processed near
the accuracy rates of many other industries and probably will
not be for some time. The complexities of many provider contracts
and benefit plan designs have created a tremendous amount of
subjectivity in the processing of those transactions. This creates
a unique need for claims auditors with experience specific to
the healthcare industry. One can hardly ever apply a similar
set of criteria across multiple data sets to identify a single
overpayment issue. The team must allow flexibility, while consistently
representing the financial and business interests of the client.
This is a difficult balance that Healthcare Horizons strikes.
On each engagement, we utilize experts who have worked for claims
payers and understand their environment and challenges. While
running logic against a data set is the critical first step,
our process of Search and Rescue covers much more in order to
maintain the working relationship with the claims payer while
maximizing the financial impact of the claims audit.
Search: The claims auditor must quickly ascertain
likely areas of problems based on the initial review of plan documents and queries
against the data. The Search process accounts for the variability required in
claims payment to focus on those areas where claims errors are likely to occur.
Rescue: It takes special skill to sit down with
a claims payer and challenge their normal line of thinking to turn Search results
into recovered dollars. One must navigate around road blocks, push through delays,
and ultimately produce enough documentation to support the additional work required
for the claims payer to correct overpaid claims. Rescue turns Search into real
money for our clients.
