Compliance confusion

Most of us are naturally hesitant about changes to routine. This is especially true in the healthcare industry. When minor deviations in routine have the potential to cause errors that are life-threatening or costly, it’s understandable that many in the healthcare industry are hesitant to take steps forward.

But change comes nonetheless. Around the globe, government regulators have been making moves to increase the accuracy and precision of medical documentation. One example is the evolution of medical coding standards. The ICD-10, the tenth revision of the WHO’s standard classification of diseases, provides the healthcare industry with a universal method of classifying and coding diseases and symptoms. And in the US, the ICD-10-CM, implemented in 2015 further refined coding standards. While these standards enable healthcare providers to document their patients’ care with more precision than ever before, they also introduce a new layer of complexity and cause confusion among providers.

This was the point made by Healthcare Dive in their February article, Healthcare reform can create confusion over compliance for providers. The author points out that the transition to ICD-10 has made it all too easy for providers to commit unintentional errors when submitting claims while making compliance a bigger struggle. According to the article, “Gray areas most frequently occur when highly technical billing requirements are attached to national coverage determinations. In many instances, providers have little in the way of guidance from federal regulators.”

The burden of fraud, waste, and abuse

When providers unintentionally submit improper claims, this adds to the problem of fraud, waste, and abuse (FWA). Each year, $455 billion in worldwide healthcare spending is lost to FWA – that’s over 6% of every dollar spent on healthcare. The World Health Organization lists FWA among the leading causes of inefficiency in worldwide health.

There is no doubt that ill intent is behind some of these improper claims. Physicians that intentionally over report the cost of their services in order to boost their profits and patients who shop around for unnecessary prescriptions, for example, illegally siphon healthcare funds away from their intended purposes. But even providers with the best of intentions can accidentally contribute to FWA. And because a physician’s main priority is usually to treat patients and not necessarily to comply with health plan requirements, payer regulations, or federal standards, auditors should expect a margin of error when dealing with claims.

With this knowledge, what can health plans do to accommodate the increased amount of claim errors connected to new coding standards and regulatory norms? Rapid recognition and response is key to auditing success. The longer it takes a health plan to recognize an improper claim, the lower the probability that they will be able to recover the lost funds. Furthermore, the slow process of auditing months-old claims adds to already costly administrative efforts. So when it comes to facing FWA, preparedness is everything. Health plans need to arm themselves with the tools to successfully identify and correct improper claims. Overworked auditors simply cannot manually comb through every claim in order to identify and follow up on each claim on their own. And outdated, on-premises software solutions have limited capacity for both volume and analytical power.

Finding the rights tools for the job

To ensure that auditors can detect and correct improper claims quickly and accurately, health plans need CGI ProperPay, built on Microsoft Cloud Technology and using the Cortana Intelligence Suite. This advanced analytics solution enables health plans to detect improper payment scenarios and review high-priority cases. Through machine learning, CGI ProperPay learns and applies patterns and trends in order to accurately identify improper claims and reduce false positives.

CGI ProperPay has a robust history of fighting healthcare FWA. Since 1990, health plans of all sizes have used the solution to identify and recover over $2.5 billion dollars. Now available on AppSource, the solution has been rebuilt entirely on the Microsoft Cloud to deliver vast improvements in speed, efficiency, and power that further cement CGI ProperPay as a world leader in preventing improper payments.

There is no perfect fix for fraud, waste, and abuse in healthcare. In reality, even the new standards and regulations that are designed to fight FWA can create their own problems. But health plans can take control of the situation by ensuring that they have the best possible tools for claims screening. If you’re curious to find out what CGI ProperPay can do for your organization, learn more and see a demo of the solution on Microsoft AppSource.

Jenn Roth

Director, Global Healthcare Product Marketing Microsoft Global Industry Marketing

Jenn Roth leads Microsoft’s healthcare and life sciences product marketing strategy and GTM messaging for the Global Industry Product Marketing team. She is the solution program lead for the Microsoft Cloud for Healthcare. Her experience includes hospital administration, product marketing, global communications, and commercialization across Class III medical devices and clinical SaaS applications.

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