■ OUR CLAIMS TESTING PROCESS HELPS STATES IDENTIFY AND
CORRECT ERRORS BEFORE “GO-LIVE”
Claims processing and payment errors that occur once your system goes live can be a strain on state budgets and can be financially disastrous for providers. However these errors can be identified and corrected before “go-live.” Myers and Stauffer will help you develop an effective strategy to identify and correct claims processing and payment errors so your implementation can be a front-page story in the newspaper – as an overwhelming success.
Our proven strategy includes an analysis of a large set of test claims for claim types or provider specialties, categories of service, or other criteria you choose, according to your coverage and payment policies. We test the claims in multiple iterations prior to implementation, and will provide an estimate of the potential claim errors (including financial impact) for claim or capitation transactions processed through a claims payment system. Statistical sampling and extrapolation are used to determine the estimated mispayment should the system “go-live” without modification or correction.
The fiscal agent contractor adjudicates the test claims and provides the adjudication results. Myers and Stauffer analyzes the results to determine how the claims adjudicated in comparison to your coverage and payment policies. Claims that are priced at the header level are analyzed at the header level. These are claims for which information from multiple lines is used for determining pricing or where the payment policy is based upon bundled services. Claims that are priced at the detail level are analyzed at the detail (line) level. For these claims, a line has all of the information necessary for pricing and does not depend on information on other lines.
Testing includes submission of test claims through electronic formats (e.g., 837, NCPDP) and the web interface. We test transaction files and submission of managed care encounter claims. Our testing is flexible to allow for other test scenarios unique to your state.
Test claim cases are developed for high risk categories of service to facilitate the assignment of fees, rates, cutback logic, special payment rate provisions, and other claim pricing (edit/audit) situations. Test cases can include claim scenarios that are sometimes not considered during testing, for example co-payments, third-party liability, and prior authorization. We will also test for special situations involving hospital outlier payments, payments for duplicate and partial duplicate claims, positive and negative adjusted claims, and member eligibility issues. Test case scenarios can be developed to consider certain applicable benefit limits, such as maximum units, and age and sex restrictions. We will use the results of the comparison between the expected payment amount and the processed amount to generate an overpayment and underpayment estimate that you can use to determine when to “flip the switch.”