Payers are taking a cue from credit card companies by replacing "pay and chase" back-end review with a look for potential fraud before paying claims.
In an American Medical Association (AMA) amednews.com article, writer Emily Berry details how payers are using a "real time" process to stop payments until claims are confirmed as legitimate. Similar to the method credit card companies use to review sales and stop payment until the card holder is contacted and confirms veracity of the purchase, the technique not only prevents paying fraudulent claims but cuts the cost of recovering that money.
Health care fraud prevention companies say providers find savings in not having to find and provide supportive documentation months later. The AMA article does raise the spectre of "false positive" holds, which are often poorly communicated to providers and amount to between 30 to 40 percent, if using sophisticated claims analysis software. However, as high as this sounds, some payers who are using older methods are finding up to 90 percent of claims tagged as false positive.
This mens payers must use highly tuned systems that find fraud without casting too wide a net, the article says.
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Practice Management