Case study: Claims audit tool identifies $1.7 million in overpayments
A large medical system improved its claims auditing efficiency, immediately identifying overpayments and underpayments, and projecting $8 million in savings.
A large medical system with more than 510,000 patients is among the most innovative full-risk medical systems in California, Arizona, Texas, and Rhode Island.
It has a management services organization (MSO) that processes claims for its affiliated entities. Services include primary care and specialty physician services, acute care hospitals, skilled nursing facilities, behavioral health, and wellness services.
It contracts with most major health plans, and serves all product lines, including:
- Commercial
- Medicare
- Medicaid
- Medicare-Medicaid (Medi-Medi)
- Health Insurance Exchange
The situation
The client licensed the AccuCAT™ application to replace its homegrown claims auditing application. The previous software application had limited capabilities and was preventing their in-house audit team from reaching its full potential.
As a result, the audit team was able to perform very reduced prepay audits and they had a backlog of post payment audits.
The solution and results
The client has used AccuCAT™ to dramatically increase the efficiency and effectiveness of their audit team.
The tool has enabled them to focus more heavily on prepayment audits. As a result, many more errors have been identified and corrected before payments and explanations of benefits (EOB) are sent.
In the first two months after the application went live, auditors identified more than $1.7 million in overpayments and $370,000 in underpayments. The application paid for itself many times over in less than 60 days.
The client projects identifying more than $8 million in overpayments in the first year of use.
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