Don’t Settle for “Just” A Claims Editing Solution

Look beyond claims editing solutions and find a comprehensive solution to payment integrity.

If your payment integrity strategy is limited to just a claims editing solution, your health plan is falling short on the payment integrity continuum. Health plans that think beyond claims editing see bigger returns and make strides toward the holy grail of a payment integrity program: cost avoidance.

Let’s start by taking a look at what your health plan could be missing out on if a claims editor is the sum total of your payment integrity efforts.

Mind the gaps

Claims editing, usually built into an adjudication system, will provide a health plan with some benefits. They check every claim for basic coding errors, coverage rules, and common industry edits. For example, National Correct Coding Initiative (NCCI) bundling logic, duplicate-claim edits, and age/gender conflicts. 

However, primary editors leave significant gaps that routinely allow overpayments to slip through.

A primary editor’s purpose is to automate clean-claim adjudication; it is not a comprehensive payment-integrity platform. Without a purpose-built secondary-edit capability that brings advanced coding, clinical, and revenue-integrity logic upstream, health plans risk leaving 1–3% of medical spend unprotected from overpayment. Several factors explain the limited coverage.

1. Narrow edit scope and static rule sets

Primary editors focus on a fixed library of standardized edits such as NCCI bundling and some duplicate/frequency checks. They rarely include the specialty-specific, locally customized secondary edits that catch improper units, inappropriate modifiers, DRG shifts, or service-to-diagnosis inconsistencies. In addition, the frequency of updates may not be able to keep up with regulatory coding and billing guidelines.

2. “Clean-claim” bias and the rebill loophole

Primary editors are designed to accept a claim as soon as it meets minimum data-cleanliness rules. When a provider resubmits a corrected claim, the primary editor often again allows it through at the full allowed amount — even if the original overbilling pattern persists.

3. Insufficient clinical-policy and revenue-integrity logic

High-risk categories such as medical-necessity for high-cost imaging or specialty drugs, maximum units of service, inconsistent outpatient psych services, bilateral-procedure modifiers, and Z-code misuse typically fall outside the reach of the primary editor.

4. Lack of configurable controls and audit trail

Vendor-run secondary-edit engines usually offer granular inclusion/exclusion logic and transparent adjustment workflows. Conversely, core claims editors are often “black-box,” offering limited visibility for PI teams to tune rules by line of business or to avoid duplicate contingency fees on repeat denials.

But in an industry characterized by change, understanding methodologies is imperative to being able to process claims as accurately as possible.

Cost of Missed Opportunities

These gaps all have one thing in common: they all lead to greater inefficiency and limit productivity.

• Limits a health plan’s post-pay identification efforts.
• Makes proving the ROI on claims editing efforts much more difficult. There are no internal BI capabilities, and even if there were, they’d only be showing one part of the payment integrity process.
• Overlooks goal setting and accountability capabilities needed to better manage third-party services vendors.
• Inadvertently contributes to data silos (a problem that CMS is actively taking on) by addressing only one piece of payment integrity.

Progress along the payment integrity continuum can be measured by a reduction in the number of manual interventions required to keep things running smoothly for a health plan. No matter how automated your claims editing solution, the data silos alone created by this short-sighted approach can negate any gains.

Expand your opportunities

In contrast, total payment integrity consists of a more comprehensive solution to many moving parts, addressing the gaps of claims editing software by offering data mining and complex audit management, coordination of benefits (COB), and third-party vendor coordination.

Rather than addressing one singular aspect (claims), a health plan can extend their efforts and better manage their revenue operations by utilizing a more comprehensive platform that views payment integrity as a holistic program. In addition to claims editing, a total payment integrity solution opens up a whole world of opportunities for health plans:

• Improved post-pay activity with first-pass, third-party vendors for major services (such as data mining, clinical audit, and COB) which complements internal post-pay efforts.

• Comprehensive post-pay activity with additional vendors. With a total payment integrity platform, a health plan can leverage vendors as R&D to expand internal post-pay efforts in order to optimize spend. This reduces the amount of manual intervention required to effectively manage third-party vendors.

• A third-party, post-adjudication prepay vendor to complement post-pay efforts.

• Adding post-adjudication internal prepay operations in advance of third-party solutions. This ensures a health plan is continuing to round out post-pay activity.

With total payment integrity, all lines of business are addressed pre- and post-pay. Plans realize cost avoidance in excess of 50% of overall plan savings. Dynamic solutions are put in place to continuously evaluate and move post-pay identifications internally, ultimately leading to avoidance.

Where is your health plan on the payment integrity continuum?

Total payment integrity offers health plans a comprehensive platform with integrations and tools that require fewer manual interventions. As you take stock of where your organization falls on the payment integrity continuum, keep in mind that the current healthcare climate seeks transparency and access to quick information.

A claims editing solution falls at one extreme of the continuum, as it silos information and limits (or fails to supplement) post-pay identification efforts. Such an approach may be a temporary band-aid for health plans seeking to stop payment leakage, but it won’t hold for the long term.

What is required in order to stay on the progressive end of the continuum is addressing claims on a pre- and post-pay basis, while cost avoiding more than 50% of overall plan savings. Total payment integrity is a possibility that is achievable for health plans, especially those who are committed to seeing the bigger picture.Learn more about the ClarisHealth 360-degree solution for total payment integrity, Pareo.