A good audit can enhance the claims department and the individual adjusters, whereas a bad one can ruin them. If it's necessary to refresh your memory, review both the contract you signed with the plan’s administrator and the insurance plan. The Claims Audit Tool™ (CAT) is the solution that finds claims which require intervention and can streamline and automate the necessary steps to correct the errors, improving process quality and payment accuracy. Executive Summary The City of Virginia Beach engaged Healthcare Horizons to perform an audit of claims processed by Optima Health (Optima) for paid dates of April 2014 through December 2014. The result is this comprehensive discussion of the audit process. For example, if you are missing documentation, try to locate it.". It is calculated by finding the difference between claim amounts actually paid versus the amounts that should have paid if all the correct data and guidelines were correctly applied. The auditing process begins with your compliance plan. What is claims auditing? Claims leakage is the amount of money paid out or lost because of oversights and inefficiencies in the insurance claims process. Client involvement is critical at each stage of the audit process. Subscribe to HIM-HIPAA Insider! Fieldwork. Audit all medical claims within a specific period or choose a random sample of up to about 250 claims. A claims auditor ensures that policyholder claims, or requests for reimbursement, are valid and accurate. To review documentation, choose a claim (e.g., radiology patient) and a line item from the claim (e.g., magnetic resonance imaging [MRI]). Use the following nine steps to analyze data easily and effectively and ensure that you pay claims accurately and on time: Prospective audits-those conducted prior to billing-allow you to identify and fix coding and documentation errors before submission. For instance, an auditor reviews a car insurance policyholder's request for reimbursement. J. Graham Inc. follows a transparent process that works with you to maximize your return on investment. There are numerous approaches and benefits of a medical claims audit. share on facebook share on twitter Healthcare Horizons received $78,126,256 in paid Standardize the tracking of audit results and errors to facilitate … Also determine whether to use a random sample or a statistical sample. Tell us about your claim and you'll be on the road to saving money in no time. "As long as your sample is representative of the entire population, you can draw conclusions based on a small sample size that can be extrapolated across the entire population," says Kozik. Within your overall compliance plan, include a provision for auditing and monitoring coding and billing. CAT ™ streamlines the claims audit workflow and reporting process. Program Audits section page. Contractual Risk Transfer. Worried about the complexities of the new rules under OPPS and APCs? The audit of claims or vouchers (the terms are used interchangeably in this publication) is a classic internal control activity. CAT scans claims both prepayment and post-payment to identify anomalies and address them based on your business requirements. Applicable types of claims include, but are not limited to: 1. "You should also watch for policy-related errors, such as procedures not matching organizational policies," she says. Then, ensure your audit routine matches what your compliance plan requires. With a user-friendly frontend and powerful relational database backend, clients use CAT ™ to facilitate pre- and post-payment claims audits. Cognizant Open Claims Audit helps managers review claims automatically—before closure—and reduce errors that could lead to loss. Obtain the patients' medical records, including the physician documentation, and follow the documentation to the UB-92 claim form to make sure that what the physician ordered was billed and coded accurately. For the reverse process, select a list of patients. Fieldwork is the first active auditing stage. According to the Society for Human Resource Management, a randomly chosen sample must include both the lowest and highest paid claims for the period. Performing a claims audit does not mean you will be bogged down in paperwork for months on end. … This helps ensure that both the payment and the process used to calculate the payment are correct. If you’re also conducting a process review, continue analyzing each claim for proper categorization and coding. data is processed to see where edits and audits impact the claim adjudication process. Any contracting party needs this IRMI best-seller within arm's reach. Inc.: Your Obamacare To Do List: Explore A Self-Funded Plan, EisnerAmper Accountants and Advisors: Paid-Claims Audit For Self-Insured Companies. For the reverse process, select a list of patients. Phone: 800-521-7703 | Fax: 800-521-7704 | Email us here Other times, coding errors exist, such as undercoding and overcoding. The products and services of HCPro are neither sponsored nor endorsed by the ANCC. Please contact us at National Insurers Audit Bureau Inc. In simple terms, they are where an employer signs up with an insurance carrier to provide coverage and, depending on the type of retro, actually allows the carrier to process and settle claims and then bill the employer for the claim dollars paid. If the problem you discovered affected billing, notify your local FI or carrier about the problem, including how you discovered and corrected it, and then take the necessary steps to initiate a payback. A medical claims audit measures the claim administrator’s performance in the areas of financial, payment and procedural accuracy. Claims auditing tends to be very manually intensive with mountains of paperwork to process. ... Start The Process. Claims being reviewed to validate items and services billed are documented in the medical record for

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