Improved claims payment accuracy (through more effective controls)

The challenge

A regional Health Plan was challenged with medical claims “leakage” due to a number of factors including inappropriate charges, duplicate submissions, and lack of coordination of benefits. The Plan needed to identify, audit, quantify, and recover claims over-payments, and implement avoidance measures to improve claims accuracy within the organization. They needed assistance to both recover claims paid in error as well as to establish a claims recovery capability consisting of clearly defined and repeatable processes.

Our approach

Vynamic focused on several value-creating initiatives including identification of seven major opportunities for near-term (Year 1) claims overpayment recoveries and calculation of statistically valid financial savings. Vynamic managed a team to perform statistically valid audits on a subset of claims for each recovery opportunity. Additionally, Vynamic implemented avoidance measures and led claims processor training to stop future “leakage.”

The results

The Health Plan became more efficient in processing claims and in identifying other areas of recovery opportunities.

Some specific results achieved include:

• Identification of over $41 million in claim recovery and avoidance savings
• Creation of a pipeline of prioritized and quantified opportunity areas on which to focus future recovery and avoidance efforts
• Establishment of a capability within the organization to identify, audit, quantify, and recover overpayments on an ongoing basis