In the healthcare sector, payment integrity is central to ensuring that healthcare dollars are spent accurately and efficiently. Payment integrity processes, designed to prevent claim inaccuracies and fraud, are structured in multiple stages, each containing a series of passes—1st, 2nd, and 3rd—across both pre-payment and post-payment phases.
This article explains these passes with respect to code editor programs, highlighting the nuances of these passes. Claims Editing Software (Code/Claims Editor) is the first line of defense in the payment integrity process. Claims are run through a claims editor, which has a standard code-edit set and a standardized computer program that enables the elimination of “unclean” claims and unnecessary appeals, as well as the move to real-time adjudication of claims. Payers might use up to 2-3 claims editing software (Multiple passes). We also demonstrate how modern payment integrity solutions can address these challenges across pre- and post-payment processes.
Breaking Down Payment Integrity Passes for Pre-payment and Post-payment
To clarify the structure of payment integrity processes, it is important to understand that both pre-payment and post-payment code editor reviews consist of the first, second, and third passes, with each pass, adding more layers of checks, validations, and audits. Post-payment edits are developed through data mining, and these passes are automated. A code editor solution is the first line of defense in pre- and post-adjudication. These layers are designed to reduce errors, fraud, and waste while enhancing the accuracy of payments made to healthcare providers.
Pre-payment and Post-payment Code Editor Passes
- First Pass (Initial Automated Claim Validation): The first pass, also generally called primary editor, focuses on the basic automated validation of claims before any payment is initiated. Automated systems check for common issues such as claims processing guidelines, data validity checks, improper coding, and contractual compliance. At this stage, the payer ensures that all required data is present and that the claim aligns with general policy guidelines. The goal of the first pass is to catch the most obvious errors early in the process, thereby reducing the likelihood of more complex issues down the line.
- Second Pass (Advanced Automated Checks): The second pass involves more sophisticated automated checks, often powered by rule-based engines or AI technologies. This pass digs deeper into clinical appropriateness, service utilization, and compliance with more complex payer rules. For example, in Medicare, this might involve additional checks against specific CMS guidelines, while commercial payers might run deeper checks against network contracts or service agreements. The second pass aims to identify issues that require more nuanced understanding and higher-level review.
- Third Pass (In-depth investigation): The third pass is a filter before payment authorization. In this stage, the code editor is used for advanced coding and clinical validation. Code editors can be configured to run highly specific coding validation rules that account for nuanced clinical guidelines and payer-specific policies. Additionally, the code editor can streamline documentation requests and provide decision support, significantly reducing the volume of claims that require manual intervention. In cases where the automated system flags suspicious claims or where more detailed documentation is required, the claim is escalated for in-depth investigation. This pass may also involve requesting additional information from the healthcare provider to validate services rendered. It ensures that claims leaving the pre-payment phase have undergone a comprehensive review, mitigating the risk of paying erroneous claims.
The Role of Modern Payment Integrity Solutions
The complexity and variability of payment integrity processes demonstrate the need for advanced solutions that can streamline the first, second, and third passes in both pre-payment and post-payment stages. Traditional, manual-heavy approaches can no longer keep up with the demands of today’s healthcare environment.
This is where modern solutions like CoverSelf come into play. Managing too many vendors, programs with escalating IT costs and lack of control with no single-view visibility is becoming a big problem for payers. With a solution like CoverSelf, all these programs can be managed in one single platform, avoiding the above problems. Most of the work is insourced and only a niche work is outsourced by direct integration or through API calls.
By leveraging cloud-based technology, AI-driven automation, and transparency, CoverSelf is transforming the way payers handle payment integrity. Offering both pre-payment and post-payment capabilities, CoverSelf can seamlessly integrate with claim systems and applications, reducing reliance on external dependencies, enhancing accuracy, and lowering costs.
With an advanced CoverSelf self-help platform, healthcare payers can perform detailed reviews, automate eligibility checks, detect inaccuracies early in the pre-payment process, and efficiently recover overpayments in post-payment phases. This level of innovation not only drives efficiency but also helps healthcare payers meet regulatory requirements and improve provider relationships. Additionally, CoverSelf helps in “shifting left” from post-pay to pre-pay with one single platform that constantly reduces the administrative costs involved in the post-pay process and reduces provider abrasion along with continuous provider education.
As payment integrity continues to evolve, choosing the right solution is critical. A comprehensive payment integrity solution, like CoverSelf, provides the platform and tools necessary to navigate the complexities of Medicare, Medicaid, and commercial insurance. It empowers payers to take control of their cost containment efforts, reduce administrative burden, and ultimately improve healthcare outcomes. We assist payers in efficiently realizing their vision of insourcing, providing comprehensive support and services throughout the transition while building trust along the way.
