ing drastic cost reductions, the need to stem fi nancial losses from these areas has intensifi ed, along with the need for better transparency and collaboration among payers and providers. T e implementation of ICD-10 represents another major
disruption, as the change allows for interpretation during the claims coding process, inviting abuse. Complex payment models will make it harder to process claims correctly or un- derstand whether services are necessary or being duplicated, creating waste. Further, most plans currently process payment claims separately from the systems in which they manage provider connections and utilization and investigate fraud and abuse. Each is operating off independent, disparate data and viewing various facets of the same problem, without seeing the big picture. By broadening prevention eff orts to tackle waste and abuse – not just fraud loss retention – and thinking of it in a phased approach that leverages comprehensive, real-time analytics and creates a dataset that enables payers and providers to work together, the larger need to increase collaboration and address systemic problems to deliver better, less costly care can be solved: 1. Discover. Find areas of claim- or provider-level aberrance that you wouldn’t otherwise know about without labor-intensive paid claims auditing or pure serendipity.
Triage. Quickly analyze findings of aberrance to identify potential level of waste or abuse and address it within the right areas of your plan.
3. Optimize. Address patterns of waste or abuse not only through provider education, but also by fi xing issues within your systems, contracts or policies.
Waste, abuse and fraud may represent one more challenge
confronting the industry today, but what if health plans could catch major coding and billing discrepancies in real time and address them before they become bigger, more costly problems for both the payer and provider? What fi nancial and clinical impact could it have if we were able to direct those billions of lost dollars toward patients and better care delivery?
Michele Hibbert-Iacobacci, CMCO, CCS-P, VP, information management and support, Mitchell International
A plan of action is imperative T e Oct. 1, 2014, ICD-10 “doomsday” deadline is loom- ing, and many healthcare providers fear they won’t meet the target date of completion. However, there is light at the end of the tunnel. As long as providers are taking the appropriate steps to prepare themselves for the implementation of the new codes, as well as software developments in the healthcare technology industry, they can expedite the process and elimi- nate pain points.
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