02 — Capability · BC-1870.60
Payment Integrity
Pay each claim once, at the right amount and only when the plan truly owes it, by catching errors, fraud, waste and abuse before payment where possible, recovering overpayments after, and pursuing other parties who should pay first. Employee misconduct is compliance.
- Program Integrity
- Cost Containment
- Payment Accuracy
In scope
- Prepayment claim edits and reviews
- Postpayment audits and overpayment recovery
- Fraud, waste and abuse investigations
- Coordination of benefits and subrogation
Out of scope
- Coding compliance audits on the provider side (see BC-1840.20)
- Capturing a patient's other coverage at registration (see BC-1810.30)
- Employee ethics and conduct (see BC-140.30)
- Litigation against providers or members (see BC-150.40)
Realized by · 2
- ServiceNow · Healthcare and Life Sciences Service Managementpartial via BC-1870.60.30
- HealthEdge · Payment Accuracy Edgestrong via BC-1870.60.10
Used in · 2
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 5
- BC-1870.60.10Prepayment Claim ReviewApply coding, frequency and pricing edits to claims before payment, and review flagged claims against the record.
- BC-1870.60.20Postpayment RecoveryAudit paid claims through data mining and record review, and recover overpayments from providers with proper notice and appeal rights.
- BC-1870.60.30Fraud, Waste & Abuse InvestigationInvestigate providers, members and others suspected of fraud, waste or abuse, refer cases to authorities, and act to stop further loss.
- BC-1870.60.40Benefit Coordination & SubrogationFind other coverage that should pay first, including other plans, workers' compensation and liable third parties, and avoid or recover those costs.
- BC-1870.60.50Payment Integrity AnalyticsMine claims data for patterns of error and abuse, size the savings, and tune edits and audits to match.