We’re making some changes in how we process high-cost claims

We’re implementing several enhancements to our current process for handling high-cost claims to better meet the needs of our provider partners and customers.

Enhancements include expediting prospective payments and expanding pre-payment high-dollar reviews.

Health care providers have told us they’re dissatisfied with the timeliness of the prospective payment process for high-cost claims and the disruption caused by post-pay audits. They’re also seeking pre-pay solutions as a way to improve payment accuracy, avoid overpayment recoveries and control unnecessary costs.

To help us address these challenges, we’ve established a strategic relationship with Equian, an industry leader in pre-pay solutions. Starting May 1, 2017, Equian will begin reviewing certain types of high-cost inpatient claims to detect and resolve errors before payment. Equian’s advanced analytics and service delivery model helps ensure their reviews are completed within five days, using only an itemized bill for input.

We’ve already made several enhancements to our process. For example, the process of identifying outliers for review will occur weekly versus monthly starting in mid-April 2017. And we’ve streamlined internal processes and approval workflows. We expect these changes will accelerate prospective payments by at least four weeks.

The result we hope to achieve by these changes is that all claims will be paid right the first time. This will reduce administrative costs and the need for multiple adjustments, speed up claims payments and help us build trust with our provider partners about the integrity of our payment process.

We’re collaborating extensively with health care providers to make sure these changes are implemented in a way that meets their needs and the needs of our members. As part of that effort, we hosted a webinar with key facilities Feb. 22.

If you have any questions, contact your provider consultant.