Payment Integrity Guide for Health Plans

This guide outlines strategies for achieving payment integrity within health plans. It emphasizes the importance of preventing inappropriate claims payments, which can lead to significant costs undermining member care. The document discusses both prepay and postpay solutions, highlighting advanced analytics, pause-and-review programs, and data mining. It details the necessity of a robust claim editing system as the first line of defense, including adherence to guidelines from organizations like CMS and AMA. Furthermore, it presents best practices for maintaining claim editing systems, including the need for constant updates, regulatory alignment, and technical support. The guide also emphasizes the importance of utilizing analytic resources to identify issues such as over-coding. By implementing effective claim editing processes, health plans can reduce provider abrasion and ensure compliance, ultimately protecting funding and enhancing relationships with providers. The guide serves as a comprehensive resource for health plans aiming to optimize their payment integrity initiatives.