Achieve Success in Claims Editing
Health care affordability is top of mind for health plan leaders, with increasing pressure from government and consumers to bring down costs. Properly editing all claims is at the heart of ensuring accurate payments and avoiding overpaying for health care services.
Download this informative success toolkit to learn five key considerations your health plan should contemplate moving forward.
Optum Video: Essential Specialty Pharmacy Claims Edits
- Hi, I'm Kelly Romsdahl at Optum. And my team specializes in making claims editing work better for health plans. Today, I'm going to share with you some details to think about when setting up your Specialty Rx for specialty pharmacy medical claims editing. First, let's talk about some of the challenges unique to Specialty Rx claims editing on the medical benefits side. We've all seen the aggressive inflation around specialty drug claims. And unfortunately, our traditional means to regulate cost do not apply to Specialty Rx claims on the medical benefits side. Traditionally, specialty medications were administered through the Pharmacy Benefit Manager, the PBM. They were well managed there due to competition and rebate. However, drugs are entering the market faster and faster all the time with less information available. So the burden falls on health plans to determine if they're clinically appropriate and how to reimburse for these specialty drugs. Additionally, providers and hospitals can be incented by drug revenue, with out-patient hospital settings receiving higher reimbursements versus other sites of administration. So there is a built-in incentive to use drugs more broadly. Editing Specialty Rx claims is an important way to meet these challenges. I'm going to cover four key strategies you will want to make sure you consider in your Specialty Rx editing. First, it's good to build a clinical library with a broad set of edits around clinical appropriateness of targeted drugs and work to educate providers on your specialty drug policies. Second, make sure to match claims to the appropriate drug category and clinical edits. And make sure you are considering all codes on the medical claim, such as HCPCS, National Drug Code and ICD-10 diagnosis codes. Third, make sure you are using the most current average wholesale price, the AWP and that you are monitoring claims against the CMS average sales price, or ASP and your contracts and fee schedules. And finally, make sure there is integration with your prior authorization and claims editor so there is a frictionless experience for providers and members. Thanks for your time today. If you would like to learn more about claims editing, I'd encourage you to check out the full Claims Editing Success Kit my colleagues and I have created. Thank you.
Accelerating Specialty Rx Edits
Editing can be deployed to assist health plans in effectively managing the growing spend on specialty drugs.
Kelly Romsdahl, Senior Strategic Product Manager, Claims Edit System (CES) and Specialty Analytic Suite
Optum Video: Essential Emergency Department Claims Edits
- Hi, I'm Dianne Rose at Optum, and my team specializes in making claims editing work better for health plans. Today, I'm going to share with you some details to think about when setting up your emergency claims editing. First, let's talk about some of the challenges unique to claims editing. Professional and facility emergency spend is highly complex. And continues to grow. There is also a significant level of variability in the emergency department visit level assignment nationally. And per person spend for level four and five codes has nearly doubled in 10 years. Additionally, research indicates that up to 30% of insured ED visits and 10% of inpatient stays are potentially preventable with early symptom warnings. And finally, a CMS study showed a 13.8% error rate in ED related payment with 88.3% of these attributed to incorrect coding. With over $150 billion in total ED spend annually, that is nearly $21 billion paid in error. Editing ED claims is an important way to meet these challenges. I'm going to cover four key strategies that you will want to make sure you consider in your ED editing. First, you will want to be sure you are leveraging edits that align with CMS and industry guidelines, such as the CMS-11 OPPS guidelines and professional coding guidelines. Second, you will want to align ED edits with standard edits that consider ICD-10 reason for visit diagnosis codes and consider the intensity of the diagnostic workup CPT codes. You can determine a patient's complexities by reviewing the ICD-10 principal diagnosis codes, secondary diagnosis codes, and the external cause codes. And third, you can create a linkage between your pre-authorization and editing to reduce provider friction. Finally, you should ensure you are providing a descriptive and transparent rationale as to how and why a decision was made to lower an ED visit level. So you can gain insights and intelligence that allows for education strategies that fixes the issues upstream. Thanks for your time today. If you would like to learn more about claims editing, I encourage you to check out the full claims editing success kit my colleagues and I created. Thank you.
Accelerating Emergency Edits
What questions should health plan leaders ask about emergency department spending and how to set up related edits?
Dianne Rose, Senior Strategic Product Manager, Emergency Department
Optum Video: Making Claims Edits Work Better For Health Plans
- Hi, I'm Tanya Hendrickson at Optum. And my team specializes in making claims editing work better for health plans. Today, I'm gonna talk about the different ways you can edit claims and the options that are available to you as you work on making your editing programs more impactful. First, establishing your organization's claim editing philosophy enforcement and governance around ideation and maintenance upfront can more easily help you manage claims as healthcare evolves and organizational priorities change. To create your philosophy, you can look at your organization's strategic goals and decide what policies you want to enforce or enhance. You can also analyze your spend trends as a way of identifying areas needing prioritization to reduce payment inaccuracies. You can also determine where in the claim lifecycle you'd like to enforce edits. For example, editing an EDI enables you to communicate edits to providers sooner and may help to reduce the cost for both the providers and your organization, reducing resubmissions and manual rework. You may also want to edit before or after pricing, mid or post ajudication. Using your philosophy, you can more easily define your rules and build your content strategy. Also to consider there are multiple types of editing models; software only models where your team is responsible for deployments, ideation, management, and updates. Manage application models, where you partner with the vendor to manage things like your software updates or ideation of new content driving medical cost savings, or hybrid models, combining software and service models for specific types of content or editing programs. Our team has created five key elements to review in your editing strategy. Number one is consistency and transparency to maximize provider relations. Number two is to ensure agility in the plan, as we all know how quickly the healthcare environment can change. Number three is to align your editing strategy with your growth strategy around your commercial and government lines of business. Number four is to set benchmarks. Measure and use analytics to decide what you need to adjust which goes back to point number two, in having an agile plan. And number five, have a process defined to create new rules, manage and update rules across all states and all lines of business. There are many highly tactical areas where editing can work more effectively and incorporating your organization's strategic goals into your planning can be a key driver in impacting affordability. Thank you for your time today. And if you'd like to learn more about claims editing, I'd encourage you to check out the full claims editing success kit my colleagues and I created.
Editing Solutions and Impacts
Which aspects do you have expertise and resources to manage internally and which should be outsourced?
Tanya Hendrickson, Strategic Product Director, Payer Software and Specialty Content