The correct coding review and substantiation processes was developed to assist all self-funded plan sponsors to identify improperly coded medical claims from providers and facilities. This platform assists with both the identification and the recovery of overpayments from Plan assets.
Whether intentional or unintentional, mistakes happen when physician offices, labs and facilities code the forms that bill for their services. This includes all insurance types: Medicare, Medicaid, fully insured Insurance plans, and self-funded plans. Health Care Reform and changing from the ICD-9 Codes to ICD-10 Codes will only make matters worse for the plan sponsor.
Identifying these errors requires a specialist. The technique is proprietary, state-of-the-art, robust and conducts over 3,000,000 edits on every claim looking for errors. Many administrators tout a high percentage of claims being auto-adjudicated…but is there anyone reviewing the auto-adjudication? There is no incentive for an administrator to protect the outflow of dollars as the dollars do not belong to them.
Here are some articles, press releases and links regarding miscoded bills and overpayments made to providers: