Claims Payment Integrity Audit Services

The Vendor is required to provide Payment integrity services refers to several oversight functions that ensure health care claims are paid only when legitimate and appropriate.
- The goal of payment integrity services is to ensure accurate claims adjudication and payment, taking into account factors such as payment responsibility, including identifying potential errors related to eligibility, benefits coordination, and similar considerations; billing accuracy, including identifying potential coding errors and mistakes; and cases of fraud, waste, and abuse.
- Payment integrity services will ensure that claims are paid in accordance with the contract between the health plan and care delivery organization, that is, that each service is paid at the contractually indicated price. Payment integrity services consist of several solutions that are typically segmented into pre-payment strategies and post-payment strategies.
- Pre-payment strategies are those processes that ensure accuracy before payment is made and include, but would not be limited to:
•    Eligibility of Participants and services: Confirm services submitted are for eligible Participants and that the services are covered within the benefit plan;
•    Duplicate payments: Reviews to confirm that services have not been previously paid under another claim submission;
•    High-dollar bill review: Itemized bill review for claims above a specified dollar threshold;
•    Claims pricing: Calculates accurate pricing for which payer is liable based on reimbursement methods and related rules;
•    Provider education: Instruction for/engagement with providers to help facilitate accurate coding and claims submission;
•    Claims editing: Reviews and tests rules to ensure consistency and accuracy of items listed on a medical bill; and
•    Data validation: Cross-reference claims with other data sources to verify accuracy
- Post-payment strategies, sometimes called “pay and chase,” are those solutions that focus on identifying and recouping overpayments already made to providers that contain errors. These processes would include, but would not be limited to:
•    Audits and reviews: conducting ongoing, regular audits and claims reviews to ensure compliance and accuracy;
•    Coordination of benefits (COB): Determines Participants’ primary coverage/plan; mostly done post-payment (may offer ways to identify COB-related issues pre-payment);
•    Subrogation: Reimbursement for payers by the party at fault who caused damage to the Participant;
•    Credit balancing: Identifies overpayment to provider organizations and manages credit balances; 
•    Fraud, waste, and abuse (FWA): Using historical data and retrospective analysis to identify patterns of fraud or abuse, as well as correct, and prevent FWA;
•    Data mining and analytics: using tools to identify patterns, trends, and anomalies in healthcare data that may indicate issues, as well as identifying and recovering billing or payment errors through analytics; and
•    Payment recovery: identifying and recovering funds (overpayments) from incorrect payments; or providing support for the payment recovery process.
- Audit Methodology
•    Billing and coding accuracy, including but not limited to, identifying upcoding and service code unbundling;
•    Episode of care billing;
•    Duplicative charges;
•    Non-payable add-ons;
•    Eligibility and benefit plan considerations (including, but not limited to, application of benefit maximums and treatment frequency);
•    Managed care discounts and contractual rates/provisions applied; and
•    Coordination of benefits and subrogation
- Provide clinical reviews by licensed medical personnel as needed for reviews of overpaid claims.
- Ensure all detected claims meet established audit criteria and are supported by documentation, including but not limited to, accurate tagging and attributions of each flagged claim.