Inpatient Accuracy

reduce improper high-dollar inpatient claim costs

the facts

High-dollar fee-for-service hospital bills and bills with outliers equal just 1 to 2 percent of typical inpatient claims yet often represent 5 to 12 percent of inpatient costs. Billing advocates and other health professionals also estimate that up to 80 percent of these bills contain errors. Whether providers are intentionally upcoding or simply coding improperly, these errors can add up to millions of dollars in waste or abuse. Verscend’s Inpatient Accuracy solution blends claim editing, clinical validation, and complex claim review to ensure accurate payment. We bring the best of both advanced analytics and human expertise to the process, efficiently reconstructing the course of care and expertly reviewing clinical codes to close the loop on fraud, waste, and abuse.

benefits

  • Increase policy compliance and accuracy of claim payments
  • Reduce medical and administrative costs
  • Release valuable clinical and IT resources from labor-intensive claim review and appeal support

comprehensive and accurate claim review

Our first line of defense against improper inpatient billing is pre-pay editing of claims to look for duplicates. Discovery of a duplicate could trigger recommendation for denial of either a portion of a claim or the entire claim. Each day, our clinical coding experts return validated errors to the health plan for final decisions.

Verscend's second level of scrutiny is pre- or post-pay complex claim review. High-dollar inpatient claims are identified systematically based on client determined dollar value thresholds or other criteria such as revenue code, group, facility, and plan. A Verscend facility claim analyst reviews each date on the claim by revenue code while following any state- or contract-specific guidelines to validate the bill.

Verscend's inpatient clinical experts then perform a detailed line-by-line analysis of all associated charges. Clinicians identify inappropriate charges and validate the level of care billed versus authorized. They research each line they identify as invalid and enter a reason explaining why it’s invalid.

Verscend saved one client $3.9 million on total identified charges of $21.3 million (18.3 percent) in 2015, and another $2.2 million on $13.6 million in total charges (16.3 percent) in 2016.*

*Based on actual client results. Individual results will vary by client.

more efficient appeals

Verscend's payment recommendations are sourced from nationally recognized coding standards (e.g., CMS, AMA, FDA, CPT, AAPC) to ensure that denials and reductions are defensible. In cases where providers appeal these decisions, Verscend's clinical experts process the appeals on behalf of clients, providing additional rationale to support our coding and payment recommendations.

customized support

Our Inpatient Accuracy solution is not a black box. We employ a personal touch to guide you through results, ensuring that you are trained, knowledgeable, and empowered to maximize value. The solution comes with dedicated post-launch support that includes in-depth standard and ad hoc operational reporting, as well as consultative review of claims data to determine return on investment and recommend best practices.

Our experts partner with you to configure business rules to maximize cost savings and conform to your reimbursement policies.

cost-saving implementation and pricing

Inpatient Accuracy is part of Verscend's suite of end-to-end Payment Accuracy solutions. Because the solutions all share one data feed across integrated platforms, clients can take a prioritized, incremental approach to rolling out our full suite of offerings. In other words, once you have one component up and running, others can easily be turned on without an additional implementation process. This approach allows you to launch new capabilities faster while saving you money.

Rather than standard software license fees, our Inpatient Accuracy solution is priced as a contingency contract. This approach aligns incentives between Verscend and our clients.

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end-to-end

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