Optimize Payment Accuracy with History-Based Editing

40-cents per professional claim. That’s the average savings payers generate after turning on a single feature in Source, HealthEdge’s payment integrity solution.

How is that possible? The process is  complex, and the rules change often, but the History-based Editing capability embedded within Source automates the entire process – identifying any claims over the past three years that may be impacted by current claims during the normal editing process. It then returns the accurate claim amount prior to the payment being made.

On average, health plans that use history-based editing report a savings of 20% per impacted claim. And this comes at a time when managing costs and creating new operational efficiencies are the top two most important issues facing health plans today, according to the latest Annual Health Plan Market Report that surveyed more than 300 health plan leaders.

Let’s look at a real-world example.

The Source professional services team recently partnered with a large payer to perform a data study to determine the impact of this functionality on the organization’s 3.9M professional claims. The team was able to quickly identify $1.5M in savings.

Here are the raw stats:

• Average savings per all professional claims: $0.40 per claim
• Average savings per impacted claim: $38.26 per impacted claim
• Average % savings on impacted claims: 20.9%
• Most common edits: Multiple surgeries, multiple E&M, NCCI, improper billing

While exact ROI depends on a payer’s unique claims, payers have the potential not only to save money on the claims themselves, but also save on the costs associated with downstream efforts that are often necessary when history is not applied upstream in the adjudication process.

With Source, complex situations like the Medicare 3-day rule suddenly become simple. This rule requires all diagnostic services and items that are tied to an inpatient procedure three days prior to be captured and bundled on the same professional claim. Too often, items are not tied to the proper claim, and the claims get paid twice. But with History-based Editing, Source identifies this issue prior to payment being made.

Here’s how it works.

Embedded in Source is the capability for payers to more accurately assess a claim that is currently in the adjudication process based on historical claims. Source securely houses a rolling 39 months’ worth of historical member claims in an isolated, encrypted-at-rest database. The system identifies claims in history that may impact current claims during the normal editing process. It then returns editing and pricing data for the current claim in real time.

Additional details on specific historical claim line items affecting the current claim are saved to an audit database that is readily accessible to assist in reconciliation and provider relations.

Evaluating the Value: What’s Your Potential Savings?

To demonstrate the value of the Source history-based capabilities, the Source professional services team assesses three months of your data and re-runs the claims after applying optimized configurations that utilize a claim’s history. The results are compiled and reviewed with your team to estimate long-term savings and opportunities.

Optimize Your Accuracy with History-Based Editing: Getting Started

Once your team fully understands the potential savings from the data study, your organization follows these four, easy steps to start realizing the benefits.

• License the solution from Source
• System configurations to the system are made to utilize the feature
• Three years’ worth of historical data is submitted to the system via one-time transfer to initially populate the history database which informs edits
• A new data feed is established to keep the history data up to date.

To schedule your data study and determine what Source’s history-editing capability can do for your organization, visit https://healthedge.com/solutions/prospective-payment-integrity/ or email [email protected]