SYSTEMS AND METHODS FOR SCORING LOSS CONTROL OPPORTUNITIES IN HEALTHCARE CLAIMS
A method of controlling healthcare claim payment losses including accessing claim information after a payer is prepared to pay the claim, but prior to payment, evaluating the information and developing a score indicative of loss control opportunities and if the score exceeds a threshold, flagging the claim to the payer for loss control opportunities else, recommending payment, wherein flagging of the claim or recommending payment of the claim occurs prior to payment. A healthcare claim loss control system including a database having data related to claims and a scoring engine in communication with the database wherein the scoring engine accesses data corresponding to a claim when the claim is ready for payment, but before payment occurs and wherein the scoring engine evaluates the claim for loss control opportunities and generates at least one score for the claim corresponding to the evaluated loss control opportunities before payment.
1 . A method of controlling healthcare claim payment losses, the method comprising:
accessing information about a healthcare claim after a payer is prepared to pay the claim, but prior to payment of the claim;
evaluating the claim information and developing a score indicative of loss control opportunities for the claim; and
if the score exceeds a threshold, flagging the claim to the payer for loss control opportunities;
else, recommending payment of the claim, wherein flagging of the claim or recommending payment of the claim occurs prior to the payer paying the claim.
2 . The method of claim 1 , wherein the payer provides the access to the information about the healthcare claim.
3 . The method of claim 1 , further comprising routing the claim for further processing based on evaluated loss control opportunities when the score exceeds the threshold.
4 . The method of claim 3 , further comprising at least one of recommending payment of the claim and providing results of the further processing to the payer including loss control recommendations prior to the payer paying the claim.
5 . The method of claim 1 , wherein the method is performed by a third party.
6 . The method of claim 1 , wherein the score is indicative of likelihood of a fraudulent claim.
7 . The method of claim 1 , wherein the score indicates coding errors.
8 . The method of claim 1 , wherein the score is indicative of opportunities for further preferred provider organization discounts.
9 . The method of claim 1 , wherein the score is indicative of opportunities for repricing negotiation with the provider.
10 . The method of claim 9 , further comprising determining reasonable and customary charges for provided services and wherein the repricing negotiation is based at least partially on the determined reasonable and customary charges.
11 . A healthcare claim loss control system, the system comprising:
a database having data related to healthcare claims; and
a healthcare claim scoring engine in communication with the database wherein the claim scoring engine accesses data corresponding to a healthcare claim when the claim is ready for payment, but before payment of the claim occurs and wherein the claim scoring engine evaluates the claim for loss control opportunities and generates at least one score for the claim corresponding to the evaluated loss control opportunities before payment of the claim.
12 . The system of claim 11 , wherein the claim scoring engine generates a loss control recommendation based at least partially on the scoring of the claim.
13 . The system of claim 12 , wherein the loss control recommendation is returned to a payer before the payer pays the claim.
14 . The system of claim 11 , wherein the scoring results are used to update the database with a loss control recommendation.
15 . The system of claim 11 , wherein the scored claim is compared to a threshold and the claim is subjected to additional processing when the score exceeds the threshold.
16 . The system of claim 15 , wherein the scored claim is recommended for payment when the score is below the threshold.
17 . The system of claim 15 , wherein the claim score is based at least partially on one or more of:
provider integrity;
code edits;
coordination of benefits;
repricing negotiation;
data analytics; and
rapid payment discounts.
18 . A healthcare claim loss control system, the system comprising:
means for accessing information about a healthcare claim after a payer is prepared to pay the claim, but prior to payment of the claim;
means for evaluating the claim information and developing a score indicative of loss control opportunities for the claim; and
means for flagging the claim to the payer for loss control opportunities if the score exceeds a threshold, else recommending payment of the claim, wherein flagging of the claim or recommending payment of the claim occurs prior to the payer paying the claim.
19 . The system of claim 18 , wherein the means for accessing information and the means for evaluating the information comprises a database having data related to the healthcare claim wherein at least a portion of the data is provided by the payer and a healthcare claim scoring engine in communication with the database.
20 . The system of claim 18 , wherein the means for flagging the claim and recommending payment of the claim based on the claim score comprises a processor operating a claim scoring engine under defined rules and wherein the processor is further in communication with the payer.