Payment integrity process: Health care claims
Professional services firm, Aon, estimates the cost of health care now tops $15,000 per employee. So, it makes sense to have a watchdog acting as a good financial steward for your health claims.
Wellmark Blue Cross and Blue Shield's solution? Payment integrity.
In this episode of the Health Matters podcast, Heather Rodemann, director of payment integrity at Wellmark, shares how payment integrity helps employers and members manage overall health care costs.
What is payment integrity?
Payment integrity is the process Wellmark follows to ensure claims are submitted accurately and paid correctly by Wellmark Blue Cross and Blue Shield for our members.
Why do we have payment integrity?
- Filing a claim can be complicated. Doctors’ offices and hospitals must 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 the majority of the errors, dishonest actions are unfortunately a reality.
“There are so many nuances in health care billing and those nuances create an opportunity for error to occur on the provider side. Wellmark wants to be sure that those claims are free of error, accurately billed against correct claims and coding standards and paid correctly," said Heather Rodemann, director of payment integrity at Wellmark Blue Cross and Blue Shield.
That’s why Wellmark has dedicated resources, processes and analytics to ensure claims are paid accurately for both the health care providers and you.
Wellmark’s payment integrity process
Wellmark’s payment integrity process uses payment policies, analytics 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 three different points in time — when the claim is submitted, before the claim has been paid and after.
End-to-end payment review
Payment integrity looks at the full lifecycle of a claim. Because inefficiencies can exist anywhere.
Pre-adjudication: It starts here — when claims are submitted. This is our first opportunity to correct mistakes and prevent incorrect claims from advancing.
Pre-payment: When a claim has been received but not paid, we ensure accurate payment through medical record and itemized bill reviews.
Recovery: In this stage, a claim was paid, but the group is owed a refund. Wellmark makes sure the refund payment is accurate and any incorrect payments are adjusted.
After the claim has been processed, but before it’s been paid, we review areas such as:
- 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
- High dollar payments
We also review the claim through inpatient audits after it’s been paid by validating medical records to ensure it was billed correctly.
“If we did not perform our claim reviews for payment accuracy, claims might be over-paid which would result in higher health care costs and premiums for our members,” said Rodemann.
Savings for you and your employees
Following the payment integrity process leads to overall cost savings and these savings are directly passed along to you and your employees. By identifying and preventing inefficiencies, we’re able to help manage costs — reducing medical trend and administrative costs — which help create a more sustainable cost of care.
“Ensuring that our members continue to receive affordable health care is paramount to Wellmark and payment integrity is a strong tool to ensure that health care remains affordable as possible," said Rodemann.
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 blueatwork@wellmark.com.