Analyzing Claims Comprehensively

Payment Policy Diagnosis drills deeply into claims data to reveal inconsistent use of claims history, manual processing procedures and hidden business logic.

Identifying Payment Problems

Payors' stated payment policies often play out differently than intended due to multiple claims systems with conflicting rules or disjointed claims processes that introduce errors and inconsistencies. Unfortunately, these problems are typically detected only after physician calls increase or administrative costs begin to escalate.

However, Payment Policy Diagnosis works to identify and analyze deviations in claims processing by locating predictor variables for targeted unusual behavior patterns. Key drivers of these variances may include:

• Problems presented by claims processing platforms
• Workflows that bypass claim review steps
• Special accommodations afforded certain groups of physicians

Offering Solutions to the Problems

Information from Payment Policy Diagnosis allows payors to create targeted action plans, which might include activities such as physician education opportunities, process changes or the introduction of automation to existing workflows. Payors can then improve the consistency, efficiency and compliance level of claims processing in accordance with internal payment policy requirements.