how far can automated claim editing go? three fast facts you should know

Posted by Debi Behunin on 2/8/17 12:00 PM

There’s no question that automated claim editing is a crucial component of accurate and efficient claims payment. Using black-and-white sourced edits from the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association’s (AMA) CPT® book, as well as payer-sourced custom rules, these systems save plans a significant amount of money by keeping them from paying incorrect claims without human intervention.

But is having one automated claim editing system enough to ensure total claim accuracy, or are you leaving significant savings on the table without a secondary editor? And if you already have a secondary editor, is there a benefit to adding a tertiary editor? Here are three fast facts you should know about how far automated claims editors can go.

primary editors often miss improper claims, even basic ones

We know that all primary editors are not created equal, but one thing is true across the board: no primary editor will catch every improper claim. A lot of factors are in play: are edits up to date? Quarterly or less frequent updates may slow or even omit the application of money-saving edits. How are guidelines translated into editing rule logic and in what order are the rules applied? How are corrected claims handled in your system? How granular can your system’s edits get for the sake of customizing rules to match your specific plan policies? All of these factors and more may cause your automated editor to miss improper claims.

implement a secondary editor, but not the same system as your primary

The thought of extra technical maintenance and administration might tempt you to think that implementing a secondary editor different from your primary editor is a bad idea, but any administrative efficiencies of just one system are easily outweighed by the improper claim savings you’ll experience with a different system in the second position. What causes a different, second editor to catch improper claims missed by the primary editor? A different system is going to have slightly different ways of applying the same CMS and AMA guidelines, which will result in different claims being flagged. Consistently, Verscend has found that 1 to 3 percent incremental savings can be gained by implementing a secondary editor regardless of the primary editing system.

no automated editor will catch every possible scenario

So you have automated editing in place in both the primary and secondary positions. You’re covered, right? Not so fast. There are clinically complex claims that simply cannot be auto-adjudicated, requiring specific algorithms to identify and stop them, and clinical validation by a human clinical coding expert. For example, most claim editing systems allow any claim with modifiers 25 and 59 to pass through and get paid, but a team of clinicians, nurses, coding experts, or doctors can review and validate whether these claims are coded accurately. Another 0.5 percent to 1 percent of your annual professional and outpatient facility spend may be saved by a tertiary editor with fast-turnaround clinical validation.

The bottom line is that if you’re relying on a single claim editing system for payment accuracy, you’re definitely still paying improper claims that you shouldn’t be. For true end-to-end claim accuracy, experience has shown that you’ll need not only a secondary editor, but a clinical validation solution as well.


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About the author:

As vice president of clinical performance, Debi Behunin uses her knowledge of coding, reimbursement within our payment integrity division to help prospects and clients maximize their results. She has more than 30 years of experience editing claims for coding and reimbursement. Debi has been a product manager for a variety of claims editing solutions, including the initial development of PowerTrak while at Ingenix, enhancing and modifying ClaimCheck for the property and casualty market while at GMIS, and enhanced proprietary software solutions while at Intracorp, a subsidiary of Cigna. She pioneered the development of state-specific edits for group health, workers compensation, and auto no-fault lines of insurance for several claims editing solutions. Debi holds a nursing degree from Wesley Medical Center and is a Certified Professional Coder.

Topics: Payer, Fraud, Waste and Abuse