Add Blog Subtitle's.
We know that automated claim editing is unable to analyze many claims due to their clinical complexity, the most obvious examples being claims with modifiers 25 and 59. These simply pass through the system and get paid without any further intervention. That’s why clinical claim review—also known as clinical validation—is so valuable. Clinical validation is a process whereby a team of clinicians, nurses, and coding experts reviews potentially incorrect claims and makes a swift payment recommendation. Over the years we’ve heard questions and concerns from health plans about the value of clinical validation. Here are four common myths and our responses to set your mind at ease.
We’ve heard it before: you already have a primary claim editor in place, perhaps even a secondary editor as well. Why bother with clinical validation? Here’s why: while there is great value in an automated editing system, our experience has shown that clinical validation can consistently catch an additional one to three percent of total claim spending that passes improperly through a plan’s primary claim editing system. When considering billions of dollars in claims, this translates into hundreds of millions of dollars in savings!
It’s easy to understand why this myth is pervasive: it’s clinical validation, so you must need a time-consuming review of the medical record, right? Not so fast. The other procedures on the claim with diagnosis codes and claims history can tell you a lot about what’s going on with the patient. For example, let’s say a provider submits a claim with fracture care and repair of a laceration on the same date of service. Claim history indicates the patient is in the emergency room after a motorcycle accident and has suffered a fracture to the right arm and a laceration of the left cheek. In this case, it’s clear that the repair of the laceration is completely unrelated to the care of the fracture and both services are appropriately reported on the claim. The review is then quickly completed without the need to see the medical record.
We have spent the last 14 years perfecting and refining algorithms, processes, and procedures to accurately and consistently determine whether the provider’s claim has been billed correctly. You would have to make a very large investment to perform clinical validation at the same level as a third-party partner such as Verscend. Not to mention, this investment would distract you from your day-to-day operations.
However, if we still haven’t convinced you, ask yourself these questions: Do you have the financial resources to hire your own team of Registered Nurses and train them as coders? Do you have the resources to the define the policies and rationale to support clinical review of millions of code combinations that are constantly updated? Can you hire enough nurses to cover the broad range of specialties to handle appeals? Do you have the IT resources to create and constantly update payment rules in your system and customize them by provider? You will also need training and quality staff to ensure your clinical validation results are consistent, accurate, and adhere to your policies. Trying to take on such expensive and time-consuming tasks yourself doesn’t make sense when you can partner with someone who already has these extensive resources in place.
We understand the concern of provider abrasion and the additional work required when a claim denial is appealed, but working with a clinical review partner ensures that you won’t have to handle that burden on your own. At Verscend, when providers appeal our payment recommendations, our specialty nurse coders review the patient’s medical record. If our original payment recommendation stands after further review, we prepare a letter for you to send the provider, pointing to the published rule supporting our edit to give you backup. And of course, the ultimate decision of whether to pay the claim is still yours either way.
Trying to implement end-to-end payment accuracy for your health plan? Check out these best practices you should follow.