Bettering cost integrity with inpatient declare overview

Inpatient care is without doubt one of the most costly kinds of healthcare companies, the place errors might delay funds, improve supplier abrasion, and decrease member satisfaction. However the complexity of inpatient claims usually leads payers to bypass inpatient declare modifying, leading to tens of millions of {dollars} in preventable overpayments for a single group—and carrying excessive potential for supplier abrasion when the plan seeks to get well these overpayments.  

Most plans have relied completely on postpay declare overview to catch inaccuracies in inpatient DRG overview. In postpay, payers are usually in a position to recoup solely about 70% of the recognized overpaid quantity at an extra restoration expense. In Cotiviti’s expertise, the time to recoup worth from postpayment identification can exceed 90 days (Determine 1).

Determine 1. Challenges in optimizing worth with retrospective DRG overview.

Prepay declare overview eliminates the pay-and-chase method, the place the plan pays the declare, identifies an overpayment, and is tasked with adjusting the declare and getting ready an offset or pursuing restoration. Although retrospective overview is a great tool to report declare inaccuracies, implementing prepay overview can scale back the monetary and administrative burden of improper funds.

A complete and tailor-made cost integrity program that screens inpatient declare spend can shield member advantages and assist guarantee accuracy from the beginning. Inpatient cost integrity isn’t restricted to reviewing DRG claims. By introducing new and expanded inpatient cost coverage content material to current automated prepay last filter overview practices, Health plans can make the most of full member contextual processing, trying throughout skilled, outpatient, and inpatient claims.

Seize new alternatives to enhance your cost accuracy and find out how Health plans have achieved better cost accuracy by way of innovation and improved effectivity with prepay DRG overview and expanded cost coverage content material.