3 reasons retrospective solutions are a vital part of claims payment integrity

Prospective payment integrity solutions are gaining traction among health plans lately as a way to lower medical costs and improve relationships with providers. However, prepay solutions are only one tool available to ensure payment integrity: the foundational value of retrospective solutions, particularly for complex claims, makes them a vital part of any successful enterprise payment integrity program.

When it comes to payment integrity, prospective solutions are lauded for how much they accomplish before payment. And indeed, prepay solutions help speed the payment process so that claims can be verified faster. But prepay solutions are based on an existing high level of confidence in the accuracy of the claim information, which is most effective for less complex, routine claims. Postpay solutions are necessary to handle complex claims that require deeper scrutiny for verification. Claim complexity increases as data, validation, and timing requirements rise—and the more complex the claim is, the more plans need to rely on retrospective solutions.

Here are a few scenarios where retrospective payment integrity solutions are preferred and even necessary.

Additional scrutiny for complex claims

Although payment for many claims can be automated, complex claims benefit from an added level of examination. In fact, part of the benefit of postpayment integrity solutions is that they can often catch more problematic claims than prepay solutions can, whether due to the technological limits of a plan’s system or due to prepay time constraints.

Simpler claims align to pre-approved policies and require only claim data for validation, but more complex claims need additional data or provider outreach and can benefit from going through a postpay data mining solution. This is because postpay data mining solutions can catch issues such as complex incorrect modifiers, procedures, or revenue code mappings; multiple claim payments; or corrected claim modifications that prepay solutions may not capture.

Human intervention for outreach and judgement

Claims that are even more intricate require a human touch to accurately analyze. After a thorough cycle of automated data mining to flag possible incorrect claims, human intervention from certified experts offers an in-depth, white-glove touch to claim editing. The human intervention component of a postpay solution can perform outreach and verify claims manually, or make judgement calls that automation can’t handle. Human intervention can identify billing errors that need to be corrected, invoice or billing reviews, complex unit issues, or simply wrong information, such as claim edits that target incorrect providers or services that automated prepay processes would not identify. Other examples include contract-based reviews to ensure the intent of all terms, service-level definitions, and controls to ensure that rate hierarchies are applied correctly.

Clarity for claims triggered by future events

Postpay solutions are an imperative for claims that will be triggered by events that haven’t yet occurred. From late charges to retroactive fee schedule changes, there are many scenarios requiring a complete and thorough review of services over multiple claims and dates of service. Retroactive terminations are a good example of this. As dictated by the Affordable Care Act, retroactive terminations are only allowed in specific scenarios, and require a second look to verify. They therefore must be verified after the fact.

Other examples of increased complexity involve scenarios such as:

• Claim-level duplicates
• Corrected claims
• Retroactive contract pricing issues
• Medicare/other insurance primacy confirmation
• Drug frequency

Using postpay solutions in concert with prepay analytics is the key to a well-rounded payment integrity strategy. Whether as an added verification measure, a need for human intervention, or to navigate multilayered complexities, plans should consider what balance of postpay and prepay intervention work for them.