Healthcare providers, including hospitals and physician groups, must effectively manage a broad network of direct and indirect contractual agreements. If performed manually, analysis of insurance payments in accordance with hospital contracts can be both tedious and time consuming. A specialty hospital was struggling to:
- Analyze all patient information
- Identify payment compliance
- Improve contract negotiation
- Identify discrepancies for financial recovery
An employee was assigned to manually monitor and compare insurance payments with contractual provisions. Given the amount of information and required analysis, they were only able to analyze a small sample of the population of claims submitted for reimbursement each week. Purpose-built software to monitor the insurance payment process cost around $180,000 per year.
The hospital turned to data analytics expert and Integration Partner Chris Peters with GPS Consultants, LLC to see if there was a more affordable solution available. Peters started by working with the three main insurance companies the hospital contracted with to develop an automated process for capturing and analyzing information. He reviewed all the clinical database information, procedure codes, claim information, and other data. He then used CaseWare IDEA® to join the information with the claims database to compare it with the provisions of the insurance contracts and actual payments.
Peters used the Visual Script feature in IDEA to capture, edit and customize each task to automate the entire process. Custom IDEAScripts were developed to search for variances between the clinical database information, procedure codes, claim info, and other areas, to compare that data with the insurance contract agreements.
IDEA’s Visual Script feature allows you to automate any repeatable task and convert it into an IDEAScript without writing any code. Read more about creating IDEAScripts
Running the script was as simple as opening an attachment in an email. Staff could import data for the week, month or other designated time period to:
- Browse the database of exported files
- Search for overpayments or underpayments
- Search for timely payments
- Identify denied claims
- Identify other discrepancies that required further research
The newly automated process, which now allowed them to review 100% of all claims, allowed staff to focus on resolving the reimbursement discrepancies on claims that were not paid in accordance with provisions in the contracts. They immediately found discrepancies that required further attention, some of which totaled thousands of dollars.
Peters also identified a provision in the contracts that impacted the reimbursement rate on inpatient procedures. The provision enabled the insurance company to pay the hospital’s charge master rate if it was lower than the insurance company’s contracted case management rate. Several inpatient procedures were identified and updated on the hospital’s charge master, which helped recover thousands of dollars per claim.
The new process also helped adjust contractual differences between the hospital’s prices and contracted payer amounts, and check for updates on set payment amounts to ensure the insurance companies were not defaulting to the lower charge master rates.
The Audimation Services, Inc. Solutions Development team can create custom IDEAScripts to automate any task or process. Visit us online for more information about IDEA, or email us at email@example.com with your questions.