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Payment Accuracy Helps Payer Realize $1.6 Million in Administrative Savings

A regional payer achieved measurable savings by implementing a small number of edits

Challenge

A regional payer with more than five million members wanted to address the administrative waste associated with managing inaccurate claims. Staff was spending extensive time researching claim issues and contacting providers.

Solution

Availity Payment Accuracy is a robust editing engine that sits within Availity’s Intelligent Gateway and evaluates claims before they reach the payer. Claims with errors are returned to the provider with an easy-to-understand explanation, allowing the provider to correct the claim and resubmit.

The payer implemented the Clinical & Analytics package, which validates claims against clinical content. For this initiative, the payer implemented 11 edits based on International Classification of Diseases (ICD-10) coding rules, including:

  • Anesthesia performed by a non-anesthesia provider
  • Procedure codes not typical for a patient’s age
  • Modifier that is not typical for a procedure code

Over the next three years, the program would expand to include 25 edits.

“We needed a solution that would reduce the costs associated with claims rework without increasing provider abrasion.”

Senior Director, EDI

Results

During the first year of the initiative, these 11 edits stopped over 110 thousand inaccurate claims from reaching the payer. Over the next three years, the payer implemented a total of 25 edits and estimated that these edits stopped more than 650 thousand inaccurate claims.

By calculating an average rework cost $4 per claim, the payer estimated that these 25 edits represented more than $1.6 million in administrative savings during the three-year period.

Outcome

While the payer implemented only a fraction of the available edits, the results from this small sample showed the potential savings that could be achieved by deploying additional edits. It also showed how edits can lead to cleaner, more accurate claims. This in turn helps to prevent inaccurate claims and reduce downstream administrative costs.

“Everyone benefits from cleaner data, For us, it reduces rework. For providers, it improves analytics and revenue cycle times, helping providers get paid faster. With the right edits, all parties win.”

Senior Director, EDI

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