Healthcare fraud, waste & abuse costs the industry billions each year and is expected to increase with more people entering the system through the Affordable Care Act. The Fraud/Waste/Abuse (FWA) module can help with this through online, real-time pre-payment editing of claims to find potential FWA conditions before you pay the claim. You’ll also be able to perform extensive data mining and analytics through access to our reporting database included with the module.

Relevant Healthcare Error Detection plays an instrumental role by utilizing advanced clinical editing (billing/coding Error Detection) technology to ensure that both institutional and professional claims are properly coded and compliant with applicable payer requirements. Error Detection examines the whole claim and identifies procedure-to-diagnosis mismatches, unbundling occurrences, use of nonspecific diagnosis codes, global service violations, potential unbilled revenue, and many other problem areas that can adversely affect not just claims processing, but a provider’s overall practice.  This technology is deployed using cloud or client server based technologies, and through the use of over 50,000 billing and coding error rules (based on commercial, Medicare, OIG and Medicaid policies) resulting in millions of edit combinations, post adjudication and prior to payment of the claim, this technology identifies regulated billing and coding errors for both Professional and Institutional claims.  Furthermore, customized rules can be created to meet customers specialized needs, and the unique editing, reporting, and work flow capabilities of our technology delivers significant cost advantages, maximum flexibility, quick implementation and ease of use.

“Clinical Error Detection” as Opposed to “Technical Error Detection”: Errors are specific to the clinical coding aspect of the claim including unbundling edits, ICD/CPT® mismatches, global period violations, complete local medical review policies, correct coding initiatives, provider oversights and regulatory reporting whereas other solutions only edit technical aspects.

Average savings achieved from the utilization of this system ranges from 10% to as high as 30% and implementation is a matter of minutes!  The system can utilize virtually any electronic file format and provides full HIPAA compliance under a secure internet connection to our highly secure Tier 4 data center (fenced facility, armed security, biometric entry, etc.)

FAQ

What is a billing/coding Error Detection system?
An Error Detection system provides a payer the ability to avoid the adjudication, process and payment of any claims codes that should not have been included on the claim to begin with due to either basic errors such as data entry, OCR scanning errors, etc. or coding errors as a result of mistakes as they relate to complex coding requirements and protocols.  By ‘cleaning’ the claim prior to any adjudication, a claims payer ensures accuracy, avoids the payment of charges that should be denied.

What type of errors does your system identify?
The system contains Millions of Editing Combinations that are all automated. This robust editing includes the categories noted below:

• Unbundling / Bundling – component / comprehensive  • Regulatory errors – CPT® based regulations  • Potential Fraud, waste and Abuse situations  • Medicare RAC rules  • Procedure/Diagnosis relatedness including LCD, NCD and CPT®/ICD  • Code validity – deleted or truncated codes  • Utilization errors – limited occurrence codes  • Billing oversights – missing associated services  • Miscellaneous edits – by report procedure  • Documentation – supporting documentation needed  • Linkage mismatch  • Missing and invalid data  • Common coding rules  • Place of service  • Compliance with specific payer requirements  • CCI violations  • Global period violations – follow-up to global service  • Fee schedule editing  • Gender and age edits  • Utilization and historical

How much do you charge?  What are the implementation fees?
There are no implementation fees of any kind.  Relevant Healthcare can also provide a complimentary analysis of one months’ worth of past paid claims to show the types of errors the system would have captured on those claims and the associated savings.  When the system does detect errors that equate to savings, Relevant Healthcare charges a percentage of that savings as its fee.  If no errors are found, or the errors found do not equate to immediate cost saving, there is NO CHARGE to run claims through the system.

How much can I save?
On average, the system will detect 10-30% of all claims reviewed showing errors.  Of those claims detected, on average the savings will be 20%.  In terms of dollars, on average each claim showing errors will reflect $300.00 in savings. As an estimate of savings, on a monthly basis a population will generate one claim per life covered, per month.

Using 10,000 covered lives as an example: 

  • 10,000 claims per month
  • 1,000 claims found to have errors (10%) On average, each claim will reflect ~ $250.00 in savings
  • Total potential gross monthly savings = $250,000.00 thus an estimated annual, gross savings projected at $3,000,000.00

What do you mean by ‘Real Time’ Error Detection and why should I care about that?
Due to the real-time functionality of the technology, depending on the number of claims within each file submitted daily, the system will analyze each file within a few hours on average.  Therefore, all claims are made available to the client quickly so as to not affect the timeliness of claims payments to providers. Our automated solution allows us to provide claims real-time and get sub-second response for potential aberrations.  No manual intervention is required, substantially speeding up our claims processing.  Historical data is stored at the processing source to ensure rapid processing for detection of aberrations like once-in-a-lifetime procedures and fraud, waste and abuse

Why do claims have so many errors?
As medical billing and coding continues to grow in complexity, there is simply more opportunity for errors to occur and as a result the national estimate is $380 Billion per year is overpaid as a result.  Human errors from keying claims into systems.  OCR scanning errors as a result of inconsistencies and system limitations.  And of course fraudulent billing errors as a result of medical providers attempting to find ways to maximize reimbursement levels and revenue.  Given the high costs of systems and labor involved with claims review, and how PPO discounts mask the problem for payers, these errors are quite often missed in the adjudication and payment process.  Furthermore, with the evolution of the Affordable Care Act which resulted in more patients entering the system and providers cost shifting to the commercial space, coding errors are increasing daily.

Why is Error Detection important to me?
Proper and effective claims editing can lead to a number of savings opportunities and can enhance payer fiduciary compliance and responsibility, sales/marketing, and reduce costs:

  • Lowers administrative costs associated with processing claims –
  • Improves compliance with reimbursement guidelines –
  • Reduces audit risk/costs –
  • Only adjudicate claims charges that are valid so avoid delays and costs of processing and vendor fees –
  • Promote claims payment accuracy and due diligence –
  • Identify any potential fraudulent billing via error reports generated by the system –
  • Reduce expenses by streamlining the claims process workflows

Do you help support your Errors should a provider question or appeal the edit?
Yes. The system provides an EOB with a full description and detail for any/all errors detected.  In fact we suggest to all clients to include a toll free number at the bottom of the EOBs on any claims where errors were detected and savings were incurred that connects that provider directly with someone who can answer that question and explain the edit.  Another option offered to clients is the creation of a client branded web portal where the URL for this portal, along with a unique code, is added to the bottom of the EOB allowing the provider to access the specific defense text/source for any identified error.    Furthermore, the system can provide a myriad of reports that can be generated by the client and in real time regarding any claim or any specific error that was detected.  Due to the nature of the errors found, appeal rates are extremely low.