The AHA estimates that 60% of surgeries are now outpatient – a trend that’s expected to continue.
Add to this the fact that outpatient services have complex coding, and the result is a significant, often untapped, opportunity for recovery of overpaid claims dollars. In fact, our data shows that 25% of audited overpaid outpatient claims are incorrectly coded.
Pre-pay payment integrity solutions do a good job of capturing overpayments, but they don’t catch everything, and what’s left behind is real dollars. One area, in particular, is procedures that have not been billed as performed. In the first two years of our program, we have identified tens of millions of dollars that fit into this category.
Our proprietary Total Claim Score (TCS) Engine enables us to score every outpatient claim small and large. Just as in our other provider audit solutions, TCS incorporates a longitudinal database and other key parameters to predict the change probability and financial impact. Through TCS, we identify claims most likely to have been overpaid and that will result in a financial recovery – making the most efficient use of auditing time and minimizing abrasion.
In addition, the TCS Engine allows us to be extra sensitive to pause or reduce auditing activity on any hospital or provider practice. Instead of completely halting audits, the TCS Engine can be dialed down to look at a smaller percentage of claims that will still yield significant returns.
Targeted areas include: