Electronic Medical Billing Software AG Service Compliance With the pre-payment and post-payment audits


mistaken payments add up to approximately $ 200 billion, over 10% of national health care costs. Other Party Liability (OPL) one, ie claims payable to someone else, make up $ 68 billion or 3.6% of national health care costs. The enormous size of the potential savings due to better claims processing continues to draw attention and resources focus. Insurance profitability experts believe that the payment of the examination program can be as successful on profit-building strategy for insurance companies raising premiums or add members. The growing industry of outsourced technology services to avoid incorrect payments are also signs of a growing demand for such services. Some manufacturers cited cumulative savings payments as high as $ 3 billion.

However, avoid incorrect payments is difficult because of the four-pronged constraints, ie, volume requirements, disparate and disconnected sources of relevant information, resource -intensive manual processes to identify and investigate improvement opportunities and rules timely payments.

To control this problem, many payers adopted a two-phase-based “pay-and-refund” approach for the minimization of payment. The second phase of this approach is designed to correct any mistakes made in the first phase. Each of the levels can be further divided into two stages. Specifically, the first stage is divided into prepayment review and timely payment of valid points, but the last phase involves the following payment audits and refunds of parts proven invalid revision.

Prepaid Review

Prepaid review generally goes in two stages, the identification and verification. Potential overpayment identification requires cross-referencing multiple systems that control provider enrollment, authorizations, recovery case management and call centers for both insured and providers.

Overpayment authentication uses the correct encoding Initiative (CCI), Local Medical Review Policies (LMRP), and rules to classify potential overpayments in contractual / Clinical qualifications, Coordination Benefits or Copy Policies.

Overpayment confirmation usually test for Inter-claim, intra claim or the claim inconsistent, lifetime backup, period copies, again a combination of, improper modifier code, incorrect E & M crosswalk, upcoded or under cooled visit points, etc.

Prepaid review requires a powerful database technology. Most prepayment claim review process can be automated, with subsequent denial notice or explanation of benefits (EOB).

Post-Payment Audit

However, after payment of assessments tend to consume more resources at each review stage:

  1. Target identification
    The audit identified the report shows total annual income and the variance between the audit target and peers in the same specialty and geography. The product of two numbers is proportional to the expected proceeds from the audit, primarily to provide a natural audit ranking.
  2. Audit preparation
    Higher back to the payer is the key advantage of carefully designed and built by a credit review. Audit preparation begins with a discussion of alternative targeted review, which is the result of provider profiling and variance reporting. This stage includes a list of claims paid in the past are likely to fall outside the normal distribution of the peer group.
  3. Review of the implementation of
    Auditor requests and analyzes Medical comments supporting data reflected in the sample paid claims made in the preparation of the audit level. Objective of the auditor is to establish percentage requirements are found not supported by the Medical review comments within the set of the audited sample (percent of overpayment).
  4. Refund (and penalty) extrapolation
    Auditor extrapolate refund the product percent of the overpayment and total payments of audit insurance carrier for the past six years.
  5. Negotiations
  6. Settlement

Some levels, such as the implementation of the review, negotiation and settlement must be completely manual, and may require highly skilled and experienced staff. Other levels, such as confirmation of the overpayment amount and currency, identification of the overpayment reason, and review priorities, can be partially automated, with rule-based technology to identify process repetition, high payments per day, wave analysis, unusual modifiers, unusual procedure rates, geographical improbabilities or 5/50 patterns. External resources could add at this stage to consult provided watch lists, Org penalties databases or high-risk number databases.


A full-scale implementation of payment observation needs a sophisticated approach to deal prepayment claims review and payment for withdrawals and uses advanced fraud detection technology. Prepaid claim offer cheaper after payment audits and therefore can be applied to every claim, but withdrawals after the payment must be carefully targeted. A system for managing overpayment recovery must include the requirement identification, history, present and insured information, medical notes, covered services, call center notes, sources, etc. Without the ability to efficiently manage large amounts of recovery cases, the risk of errors or missed payment deadlines is high, resulting in lost recovery opportunities.


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