In the fast-evolving and intricate landscape of payment integrity, the value of prepay editing is paramount. As powerful AI and advanced analytics are being applied earlier in the claim adjudication process, the importance of next-generation claim editing capabilities will separate health plan leaders from laggards.
If you’re equating claims editing with medical savings alone—you’re missing the boat and the opportunity. Because forward-thinking payment integrity and claims operations leaders recognize that prepay editing, and its underlying best practices, improve administrative costs, plan member satisfaction, and provider relationships.
Here are ten best practices of prepay editing, which health plans should be using today:
- Staying Agile with Regulatory Updates
In a sector governed by stringent regulations, it’s crucial for health plans to stay updated on policies and regulations from authorities that include CMS and the AMA. This proactive approach helps ensure compliance and efficiency, positioning your plan as a leader in payment integrity.
- Fostering Strategic Alignment in Claims Editing
Finding the right balance between maximizing savings and maintaining positive provider relations is critical. Building “better bridges” between plans and providers involves both applying traditional sources of rules, as well as plan policies rooted in evidence-based data and resources.
This approach improves trust and transparency, leading to more sustainable, mutually beneficial relationships with providers.
3. Harnessing AI for Enhanced Analytics
AI offers transformative potential in analyzing healthcare claims, enabling plans to identify trends and anomalies effectively. When combined with human oversight, AI becomes a powerful tool for enhancing decision-making processes.
This technology should be utilized to amplify the capabilities of your team, including experienced medical directors and certified coders, ensuring a deeper and more accurate analysis of claims data.
- Periodically Reviewing Carveouts
Regular re-evaluation of exclusions and the scenarios that lead to them is essential. This continuous process not only ensures that your claim editing strategies are current but also provides the framework needed to adjust and refine your editing strategies continually.
- Discovering Opportunities in Diagnosis Editing
In-depth analysis of current editing strategies can reveal significant untapped savings in diagnosis edits. This expanded approach relies on a comprehensive content library supported by health information specialists who bring a wealth of knowledge and expertise.
- Recognizing Efficiency Equals Economy
Streamlining claims processing directly impacts economic outcomes by reducing administrative expenses. Efficient processes, supported by robust editing tools and advanced policy management, not only save medical costs, but also conserve time and resources. Unlocking value goes beyond savings to drive greater positives across health plan payment operations.
- Preventing Post-Payment Issues
By ensuring payment accuracy upfront, health plans can avoid the costs associated with post-payment corrections. This proactive strategy in pre-payment claim editing involves foresight and prevention fueled by proper technology and clinical content library resources, supported by experienced medical directors and certified coders.
- Improving Transparency in Claim Adjudication Explainability
Enhancing transparency in claims adjudication can significantly reduce provider abrasion. By making payment policies clear and accessible, and explaining decisions in understandable terms, health plans can improve payer-provider relationships.
This transparency is underpinned by comprehensive policy management and the integration of intelligible content from respected sources.
- Aligning Operations
Health plans focused on enhancing and helping to optimize their payment integrity, must integrate underlying capabilities—across the value chain—into a unified workflow. This approach avoids conflicting edits and promotes greater payment accuracy.
The next era of operational alignment in payment integrity will be driven by AI-based platforms incorporating best-of-breed tools, advanced analytics, and robust, evidence-based clinical content assets.
- Improve Plan Member Experience
Clear communication regarding payment policies enhances member satisfaction by making healthcare costs more predictable. Ensuring that policies are both accurate and easy to understand requires a sophisticated infrastructure that supports policy automation and effective communication, key for fostering trust and clarity among plan members.
Charting the Course: Next Steps in Prepay Editing
Optimizing prepay editing is a strategic imperative that goes beyond mere compliance and financial outcomes; it’s about positioning your health plan as a leader in a complex healthcare ecosystem. By adopting these best practices, health plan leaders can ensure their operations are efficient, compliant, and closely aligned with both the needs of providers and the expectations of members.
As health plans continue to integrate advanced technologies and robust policy management into their payment integrity operations, the synergy between innovative solutions and traditional management practices will be key to their success. This holistic approach not only enhances operational efficiency but also strengthens the overall healthcare system, supporting better outcomes for all stakeholders involved.
About Mark Turner
Mark Turner, Vice President of Clinical Content & Strategy at Lyric, brings over twenty-five years of experience in delivering superior healthcare IT solutions across both provider and payer settings. He is responsible for delivering the high-quality content that drives the value for our customers and as well as setting the go forward clinical content strategy for Lyric.
Under his leadership, Lyric’s market-leading clinical content supports health plan customers by enhancing payment accuracy, boosting medical savings, improving fraud detection, and reducing provider abrasion.
