As providers care for an aging population with a growing number of comorbid conditions, making sure that healthcare services are accurately coded, billed and paid for is increasingly complex. To identify potential coding and billing errors, payers historically have analyzed individual patient claims. But this claims-centric approach can be slow, since savings depend on provider responsiveness to medical record requests — a process that can, in some cases, take several months to as long as a year.
Moving from a claims-centric to a member-centric approach to payment accuracy offers a better alternative. One of the most effective tools in this approach is the episode of care review.
The concept of episode-based models — in which resource use is measured by grouping all of the services rendered around a specified condition or procedure — has proven to be a promising development in the drive to deliver more efficient, less fragmented care. By bundling payments into episodes, providers are incentivized to increase care quality through better integration of healthcare services and improved management of resources. And in addition to addressing care quality, this approach also addresses cost containment.
Episode of care reviews can transform healthcare payment accuracy by facilitating evidence-based, clinical decision-making through a semi-automated process, without added burden to the provider. They provide a new way to follow the patient journey — from trigger event to post-acute care — and quickly identify whether the services billed make sense within the context of the episode of care.
Because decisions are made without a medical record, payers should look for episode of care review solutions that use not only advanced analytics, but also the oversight of a clinical expert well versed in medical coding and health information management — generally a nurse or medical coder.
The review leverages artificial intelligence to follow the patient journey and analyze the claim history related to an episode of care. Machine learning-driven algorithms target select claims for review by the clinical recovery specialist who examines each claim within the framework of the patient’s history. In this context, the specialist can identify mismatches between the diagnoses and procedures that resulted in an overpayment. Once a discrepancy is identified, recovery can be pursued on behalf of the payer.
Payers are realizing significant benefits in moving to this member-centric approach to payment accuracy:
- A more holistic view of patient care. An episode of care review analyzes multiple claims for a patient on numerous dates of service, across multiple providers and at many points on the healthcare continuum.
- Accelerated recovery of overpayments. Episode of care reviews reduce the recovery process to approximately 90 days or less.
- A provider-friendly approach. Episode of care reviews result in six times less provider contact than traditional records reviews. In cases where providers want to appeal, they can easily submit records as supporting documentation.
As the industry works to break down healthcare silos to deliver higher-value care, broadening the claims review process to encompass the full patient journey represents an important step in the shift toward patient-centered care.
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