CASE STUDY
Making Every Medicaid Dollar Matter
THE CHALLENGE
Medicaid claims payments integrity at risk
Committed to constantly improving operations, a national Medicaid managed care organization contacted Optimity for help to increase claims payment integrity. The company wanted to not only enhance the accuracy of routine payments, but also avert litigation associated with a dispute involving more than $50 million in claims payments.
The company also recognized potential provider satisfaction challenges if claims were not paid correctly. To best serve everyone’s interests, the client engaged Optimity to ensure smooth and accurate processing of Medicaid claims payments.
Optimity works with clients to leverage technology in order to develop efficiencies and manage performance.
OUR SOLUTION
Getting to the bottom of inaccurate claims payments
With an eye toward streamlining processes and improving data quality, accessibility, and usage, Optimity works with clients to leverage technology in order to develop efficiencies and manage performance. For this project, we built technology that not only helps the company recover leakages in claims payments but also identifies and corrects their root causes to avoid similar issues in the future.
First, we created a claims pricing engine that simulates payment of Medicaid and Dual-eligible Special Needs Plan (D-SNP) claims by comparing contract terms with claims data and reporting the expected pricing. Then, working in close collaboration with a cross-functional team composed of claims operations, contract configuration and provider subject matter experts, we examined claims payments from the previous 18 months and identified payment leakages and their root causes.
Informed by this analysis, we proceeded with a number of measures to improve claims payment accuracy and increase efficiency around payment issues. For example, we created a reusable benefits and configuration tool to identify discrepancies against the payer’s requirements. We also developed business and technical requirements to enhance the company’s claims payment issue management system and streamline the ticket submission process.
During our engagement, the company asked us to create a solution to monitor expected recoveries deriving from inaccurate claims payments. Always rising to meet the challenge, Optimity developed business and technical requirements paired with architecture recommendations for a Claims Payment Integrity (CPI) solution to track and report on claims adjustment data.
TOOLKIT
Root Cause Analysis
System Design Business & Technical Requirements Assessment
THE RESULTS
The company identified and remedied the potential leakage of $14 million in inaccurate claims payments. In addition, by providing accurate data to both parties involved in the claims payment dispute, we informed a collaborative, fact-based discussion that resulted in an agreement of $11 million in actual payments owed, saving more than $45 million from the amount originally in question.
Moving forward, 70 hospitals benefitted from contract configuration fixes to avoid inaccurate payments, and the company’s financial reporting required by state regulators for rate setting is now more accurate. And, as a result of our proprietary CPI technology solution, redundant and manual tasks around payment issues and recoveries have been minimized.
The claims pricing engine can be easily adapted for use by other organizations to maximize Medicaid claims payment accuracy for either payers or providers.
Every dollar in recovered payments is a dollar that remains in the Medicaid pool to be used for someone who needs it. And when claims payments are accurate, providers are paid more quickly, doctors can focus on healing instead of chasing down issues, and leadership in the paying organization can maintain peace of mind knowing that investments in operations are achieving corporate goals.
