With the complexities of provider contracts, creative plan designs, and the broad array of clinical interventions increasingly available to patients, errors can and do frequently occur. In-house audits and savings generated by recovery operations of healthcare payers often reveal an unacceptable level of errors in claim submission and processing, especially with complex claims such as those from institutions.
Attempts to deal with the complexity with manual audits are constrained by tight prompt payment windows and are not typically scalable. The implementation of further technology interventions is often cost-prohibitive. Excel spreadsheets and Access databases can make the process complex and cumbersome, and the results inconsistent. Managing the audits manually also makes it very difficult to monitor and report on audit performance or draw actionable insights from any patterns in the errors being uncovered.
Equian’s HiTrust Certified AuditPoint technology along with expert solutions provide a unique approach to addressing these challenges. AuditPoint couples a proprietary claim review and workflow technology platform with our full set of payment integrity solutions to produce highly scalable, productive results that significantly improve the effectiveness of claim audit operations. These solutions are customized to each client partner’s payment policies, medical policies and contracts to ensure accuracy.
AuditPoint makes it easier to analyze 100% of facility and professional claims by putting them in a time based episodic context, and applying rules-based, data-mining and profiling techniques to automatically detect situations with errors in coding, double-billing, eligibility, coordination of benefits, proper handling of outliers, contract compliance and other such common billing and claim processing issues.
The technology can also detect potentially abusive or fraudulent situations where there are suspicious inconsistencies between the billing and the patient’s medical conditions or across billing by different providers. AuditPoint can also be deployed in a prepayment modality in the future to minimize “pay and chase” activities.
The platform also includes detailed tracking and reporting capabilities that will simplify the monitoring and management of audit operations, and drive actionable insights from the auditing experience.