Health plans have developed complex webs of primary, secondary, and even tertiary claims editing solutions to improve payment accuracy in the increasingly complex world of healthcare claims processing. These solutions typically spring into action after paying the claim to identify inaccurate payments.
The good news is that these solutions often capture overpayments that represent significant savings opportunities. They also identify underpayments, which contribute to provider and member abrasion.
The bad news is that the inappropriate or inaccurate claim has already been paid, and the vendor delivering those secondary editing solutions earns a percentage of the overpayments that are recovered.
This traditional approach to reducing inaccurate payments is being challenged by some payers who are leveraging HealthEdge’s core administrative processing system, HealthRules® Payer. These payers have the opportunity to use a newly released integration of HealthRules Payer and HealthEdge Source™, HealthEdge’s prospective payment integrity platform.
This productized integration, called Payer-Source, can now be used as secondary editor without the payer needing to make a single change to their primary editing solution. By placing the integrated Source solution as a real-time secondary editor in the payment workflow after the primary editor and before the claim is fully adjudicated, payers can significantly improve claims accuracy, reduce overpayments, and streamline workflows to increase operational efficiencies.
When the Source Data Study team helped several health plans measure the potential savings of using Source as a secondary editing solution, the results were quite impressive.
- A national health plan was able to generate $8.7M, or 1.1% incremental savings, on 5.1M claims representing $790M in spend from its Medicaid and Dual-Eligible populations
- A regional health plan was able to generate $9.1M, or 1.6% in incremental savings, on 2.1M claims representing $571M in spend
- A mid-sized regional health plan was able to generate $11.1M, or 1.6% in incremental savings, on 1.7M claims representing $684M spend
Understanding the Role of Secondary Claims Editors
Secondary claims editors play a pivotal role in ensuring that healthcare claims are accurate, complete, and compliant with billing regulations. Here are some key aspects of integrated secondary claims editors:
- Claims Accuracy: Secondary claims editors improve the accuracy of healthcare claims by identifying and rectifying errors, inconsistencies, or coding discrepancies that may have been missed by primary claims editing solutions. This helps to minimize claim denials and rejections.
- Regulatory Compliance: Integrated secondary claims editors help healthcare providers and payers adhere to complex regulatory requirements and industry standards. They perform additional checks for billing accuracy, coding compliance, and documentation completeness.
- Streamlining Claims Workflow: Secondary claims editors streamline the claims submission and processing workflow by automating the review and correction process. This reduces the time and effort required for manual reviews and claim resubmissions.
To learn more about how to use Payer-Source as a secondary editing solution, HealthEdge clients should contact their account manager or visit www.healthedge.com.