In part 2 of our series we outline exactly what health plans should look for in an advanced technology platform for clinical audit
Paying claims right the first time – while making the most of internal resources – is the primary goal at most payer organizations. But, how can you best accomplish that payment accuracy ideal? In our previous article on the topic, we explored several trends that affect typical claims validation processes. To answer these challenges, many health plans are considering an integrative advanced technology platform that supports all stakeholders. This 5-point clinical audit checklist shows you exactly what to look for in a solution and what you can expect to gain. Namely, seamless collaboration between auditors and services suppliers and timely communication with providers.
5 Ways to Streamline Clinical Audits: Checklist
When it comes to maximizing payment integrity results, you may have run into a few hurdles. We find these issues tend to come down to a single root cause: manual processes. These labor-intensive workflows produce a direct hitto your bottom line in the form of decreased clinical auditor productivity. That cost is worth addressing on its own, but it pales in comparison to provider abrasion costs. The good news is the five features of this clinical audit checklist ensure necessary payment accuracy processes while addressing both of those costs.
1. Automate workflows
Even straightforward claims auditing workflows involve multiple stakeholders. Relying on spreadsheet and email tools alone perpetuates work silos and prevents true collaboration. On the other hand, an integrative technology platform can automate even the most complex workflows. This automation provides secure data access and streamlines auditor communication and activities with clear inventory assignments.
These workflows allow for sophisticated routing by audit type and configurable user profiles. Prioritized work queues with overlap control ensure internal auditors or third-party suppliers don’t work the same claims at the same time. And automated processing of all analytics and claims inventory generates results for audit and validation in real-time.
These workflows also can prevent duplicate medical records requests that can sometimes result from multi-pass audit processes. In Pareo, smart tagging triggers a nurse audit review when a medical records request is initiated, and all relevant data is easily accessible to support a quick determination. To close this loop, the auditor can generate refund letter requests to the provider including supporting clinical information. By initiating recoupment and recovery services all on the same platform, full overpayment tracking and reconciliation can occur with no gaps.
2. Validate and internalize complex analytics
Every health plan wants to build an arsenal of advanced claims concepts. If your health plan doesn’t have dedicated data science expertise, or claims auditing shares this resource with other departments, this goal can seem insurmountable.
Pareo provides a transparent view into which analytics offer the most value to your health plan. Moreover, you can maintain a centralized electronic library of queries – no matter their source – organized by category and tracked by active status. This access allows you to maximize analytics across all lines of business to gain insights into hit rates and improve accuracy.
3. Transition to more prepay claims validation
Manual, labor-intensive processes make it particularly difficult to make progress on prepay claims validation goals. The tight turnaround times require streamlined workflows and high-quality proven concepts – for both data mining and complex medical records reviews. As a result, many health plans find it easier to let third-party suppliers handle this function.
But, by leveraging the automated workflows and advanced concepts enabled by Pareo, you can better position your team to transition more claims work to prospective validation. Any post-pay concepts and processes that are particularly successful – as validated through real-time claims visibility – are ripe for this move. And the concepts repository in Pareo can apply to prepay workflows as easily as post-pay. A 10% improvement in claims recovery often occurs when health plans optimize their mix of prepay payment accuracy.
4. Blend outsourced and insourced activities to maximize efficiencies
You want to be able to base your decisions on what audit activities to bring in-house on cost-benefit analysis. An integrative technology platform based on transparency provides the detailed insights and collaboration to support those goals.
Pareo features smart staffing analysis that allows you to track internal auditor productivity in real-time and better understand metrics that drive efficiency. Audit time vs. system time, auditor activity (refunds per hour), average refund value, claims-to-refunds rate, time-based metrics and more show you exactly when it makes sense to expand internal efforts.
While you’re ramping up internal auditor efforts and expertise, strategically stacking vendors lets you accelerate your audit goals at scale. And, when it’s all managed through Pareo, you have the flexibility to decide – service by service – whether to outsource or insource or combine the two approaches.
5. Access A.I. for insights into unstructured text
As much as 80% of relevant clinical information is stored as unstructured free text. Manually evaluating hundreds of pages of medical records and other supporting documentation can result in inefficiencies and lead to inconsistencies in audits that create unnecessary friction with providers. But by digitizing clinical content to take advantage of advanced A.I. capabilities, you can minimize the provider burden.
Pareo integrates OCR technology powered by NLP and machine learning applications of A.I. that make the most of your valuable experts’ time. This multi-faceted approach includes keyword-based methods, outlier detection, context dependence, and validation against national databases and other external references. Along with making the data searchable, filterable and sortable, it creates a strong foundation for flagging suspect charges.
These audit validation enhancements unlock previously “unreadable” text – including data from images – while also creating more standardized audit processes and decision making:
- Prioritize cases for review
- Automatically identify and tag relevant documentation
- Generate confidence scores for denial decisions
- Continuously “learn” from your auditors’ feedback
Pareo Improves Auditor Efficiency and Provider Burden
Every stakeholder recognizes the necessity of claims audits. A well-rounded audit program that ensures the best possible payment accuracy rates doesn’t have to burden your staff or valuable network providers. In a recent study, 50% of providers reported that “they prefer working with payers and auditors that communicate thoroughly, provide comprehensive responses to appeals, and use staff with medical records.” This clinical audit checklist will help you accomplish that ideal.
The Pareo Audit and Clinical suites support all five features on this clinical audit checklist so your health plan can conduct data mining, itemized bill review, DRG and other audits to maximize your return on claim spend. All fully integrated on the Pareo advanced technology platform for an end-to-end payment integrity solution.
NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY
See the ClarisHealth 360-degree solution for total payment integrity in action: