Healthcare claims loss control systems and methods
View Patent ↗A method for controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, evaluating the information including at least one of determining indications of fraud, validating service coding and editing as indicated, identifying possible payment discounts, and developing analytics indicative of risk for future claims, and providing loss control recommendations based at least partially on the evaluation, prior to paying the claim. Also a loss control system for healthcare claims with a loss control engine and a database in communication with the loss control engine, wherein the loss control engine accesses information about healthcare claims from the database after the claims have been processed for payment and wherein the loss control engine further analyses the claims for potential cost savings and returns a loss control recommendation for each claim to the database before payment of the respective claim.
1. A method of controlling healthcare claim payment losses, the method comprising:
receiving a healthcare claim for services rendered to a patient by a provider, wherein a payer has screened the healthcare claim to confirm eligibility and compensability, and wherein the payer has further determined that any related deductibles have been satisfied such that the payer is prepared to pay the healthcare claim, but prior to payment of the healthcare claim; and
evaluating information about the healthcare claim for potential fraudulent activity wherein evaluating the information for potential fraudulent activity comprises:
determining with one or more computer processors whether the services set forth in the healthcare claim are for single service billings based on accessing a frequency history of past services rendered to the patient to determine whether the single service billings have occurred multiple times; and
determining with one or more computer processors whether the services provided to the patient as set forth in the healthcare claim are appropriate for the age of the patient.
2. The method of claim 1 , further comprising routing the healthcare claim for further processing based on evaluated risk of fraud or elevated potential for discount.
3. The method of claim 2 , further comprising at least one of recommending payment of the healthcare claim and providing results of the further processing to the payer, prior to the payer paying the healthcare claim.
4. The method of claim 1 , wherein the method is performed by a third party.
5. The method of claim 1 , when potential fraudulent activity is not identified, automatically evaluating the information for possible provider discounts and alternative provider discounts prior to the payer paying the healthcare claim.
6. The method of claim 5 , wherein evaluating the information for possible discounts comprises identifying opportunities for repricing negotiations with the provider.
7. The method of claim 6 , further comprising determining reasonable and customary charges for provided services.
8. The method of claim 5 , wherein evaluating the information for possible discounts comprises identifying opportunities for rapid payment discounts.
9. A loss control system for healthcare claims, the system comprising:
a database of information about one or more healthcare claims;
a loss control engine comprising one or more computer processors in communication with the database, wherein the loss control engine is configured to access information about healthcare claims from the database after the healthcare claims have been processed by a payer such that the payer has screened the healthcare claims to confirm eligibility and compensability and wherein the payer has further determined that any related deductibles have been satisfied such that the payer is prepared to pay the healthcare claim, but prior to payment of the healthcare claim, and wherein the loss control engine is further configured to analyze one or more of the healthcare claims for potential fraudulent activity, wherein the evaluating comprises:
one or more computer processors that determine whether the services as set forth in the healthcare claim are for single service billings and wherein the fourth rule further accesses a frequency history of past services rendered to the patient to determine whether the single service billings have occurred multiple times; and
one or more computer processors that determines whether the services provided to the patient as set forth in the healthcare claim are appropriate for the age of the patient.
10. The loss control system of claim 9 , wherein the database comprises healthcare claim information developed by a payer and wherein a recommendation is returned to the payer.
11. The loss control system of claim 10 , wherein the healthcare claim information comprises an adjudication of the healthcare claim by the payer prior to the healthcare claim being accessed by the loss control engine.
12. The loss control system of claim 10 , wherein the system comprises communication with at least a payer and a provider and wherein the recommendation comprises a reduction in the healthcare claim negotiated with the provider for at least certain healthcare claims.
13. The loss control system of claim 10 , wherein the recommendation comprises predictions of future high risk healthcare claims.
14. The loss control system of claim 10 , wherein the recommendation comprises at least one of the group comprising fraud identification, claim code editing compliance, and identification of additional discounts.
15. The loss control system of claim 14 , wherein the loss control engine further performs additional processing when potential cost savings are identified, wherein the additional processing comprises editing of a miscoded healthcare claim, providing additional preferred provider organization discounts, and negotiating reduced healthcare claim charges with a provider.