To identify potential coding and billing errors, payers historically have analyzed individual patient claims. Since savings are dependent on provider responsiveness to requests for medical records, this claims-centric approach tends to be slow. In some cases, obtaining medical records can take several months to as long as a year.
A member-centric approach to payment accuracy offers a better alternative. Gainwell Technologies’ Clinical Claim Reviews solution provides an episode of care (EoC) review that uses semi-automated processing to determine the accuracy of services that have been billed by providers.
The review leverages machine learning and artificial intelligence to follow the patient journey and analyze the claim history related to an episode of care, eliminating the need for medical records. By broadening the scope of analysis to the patient journey, it’s possible to rapidly identify discrepancies and recover overpayments.
Gainwell’s episode of care review has three phases:
- Identification of claims. Using raw claims data as the baseline, machine learning-driven algorithms target select claims for review.
- Claim analysis. A Gainwell clinical recovery specialist examines each claim within the framework of the patient’s history. In this context, specialists identify mismatches between the diagnoses and procedures that resulted in an overpayment.
- Overpayment recovery. Once discrepancies are identified, the recovery process begins immediately. Gainwell makes the recommended adjustments, notifies the payer and requests repayment from the provider.
Payers are shifting to this member-centric approach to payment accuracy for reasons that address both cost containment and care quality:
- A more holistic view of patient care. An EoC review analyzes multiple claims for a patient on numerous dates of service, across multiple providers, and at many points on the healthcare continuum.
- Accelerated recovery of overpayments. EoC review reduces the recovery process to approximately 90 days or less.
- A provider-friendly approach. Performing an EoC review decreases the burden associated with medical record requests — resulting in six times less provider contact than traditional records reviews. In cases where providers decide to make appeals, they can easily submit records as supporting documentation.
To learn more about Gainwell’s Clinical Claim Reviews, contact us.