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Blue @ Work

Taking a bite out of wasteful and abusive billing practices

Saving you money.

Do you remember McGruff the Crime Dog External Site? The fictional watchdog was the star of animated TV ads in the 1980s created to increase criminal awareness and personal safety.

But who is taking care of your health insurance dollars? According to The National Business Group on Health's 2020 survey External Site, the cost of health care will top $15,000 per employee. So it makes sense to have a watchdog acting as a good financial steward for your health claims.

The solution? Payment integrity.

What is payment integrity?

Payment integrity is when actions are taken to ensure health claims are submitted accurately and paid correctly by Wellmark Blue Cross and Blue Shield for our members.

  • It’s complicated. Doctors’ offices and hospitals have to navigate billing for multiple insurance carriers and comply with their unique systems, processes and benefit designs.
  • Mistakes happen. With multiple people using multiple systems and processes, there’s bound to be human error.
  • There are bad actors. While it doesn’t account for most of the errors, dishonest practices are unfortunately a reality.

“It’s not that there’s intentional wasteful and abusive practice — providers have different, complex systems for each carrier and a lot of billing turnover in staff.” — Mike Fay, Wellmark Blue Cross and Blue Shield Vice President, Health Networks and Innovation.

That’s why Wellmark has dedicated resources and processes to ensure claims are paid accurately for both the health care providers and you — which resulted in $198 million in savings in 2018 alone.

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Wellmark’s payment integrity process

Wellmark’s payment integrity process uses payment policies and claims reviews to make sure they’re free of wasteful and abusive billing practices. We do this all to give you peace of mind that your employees claims are being paid appropriately.

Wellmark began its payment integrity process in 2004 and continues to review and update it monthly to make sure everything is accurate at two different points in time — before the claim has been paid or after.

After the claim has been processed but before it’s been paid, we review:

  • Professional claims, such as those that come from personal doctors or specialists.
  • Outpatient facility claims, like those that come following surgery.
  • Cross claims to ensure your employees are not being billed more than once for the same service, prescription, or durable medical equipment.
  • High dollar payments.
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Before case study

Wellmark allows 90 glucose monitoring sensors every 75 days. A provider billed for 90 units twice within a 60-day time frame.

Wellmark denied the provider's attempt to oversupply the member.

The denial of the overage provided a savings of $1,017.

We also review the claim via inpatient audits after it’s been paid by validating medical records to ensure it was billed correctly.

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After case study

A hospital submitted a claim with a primary diagnosis of sepsis, resulting in an infectious and parasitic diseases coding. Wellmark's scheduled reimbursement was $16,463.94.

Our audit recommendation was to replace the infectious and parasitic diseases coding with a secondary diagnosis code. This changed Wellmark's reimburment to $7,986.15.

The audit provided savings of $8,477.79.

Savings by the numbers for you and your employees:

  • Applied 3.125 million edits to professional and outpatient claims and reviewed approximately 10,000 inpatient medical records in 2018.
  • These edits and reviews resulted in $198 million in savings.
  • Increased savings year-over-year: $168 million in 2016, $174 million in 2017, and $198 million in 2018.

“Payment integrity is a silent savings, but we do it because it’s right and because it’s necessary to make sure we’re accurately paying our providers and spending our members dollars appropriately.” — Mike Fay

These savings are directly passed along to you and your employees. And, by identifying and preventing these inefficiencies, we’re able to help manage overall costs — reducing medical trend and administrative costs — which help create a more sustainable cost of care.

“If we stopped doing this tomorrow, we could see a 2 to 2.5 percent increase in our premiums. That’s how much this process bends the trend.” — Mike Fay

If you’re not a Wellmark customer, ask your carrier about their approach to payment integrity. To learn more about how Wellmark is actively supporting and evaluating payment integrity for you and your employees’ health care costs, reach out to your authorized Wellmark representative, or email us at Send Email.