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What Makes A Claim A Complex Claim?

Knowing when to get an outside review on a claim could have a significant impact on healthcare payors.


What Makes a Claim Complex?With rapidly increasing claim volume and unforgiving payment times, it can often be hard to determine which claims to send for an outside review and which to keep in house. The handling of complex claims (and the recovery of overpayments) is one of the biggest drivers of healthcare costs, and knowing how to properly utilize review is a payor’s best way of combatting rising costs.

Now more than ever, knowing when to get that expert set of eyes on a claim to quickly and clearly determine the necessity of denial or recovery could make a substantial difference in loss ratio over the long term. Here are claims we would recommend flagging for further review:

High-cost claims

It may be simple, but it’s effective: Flagging high cost claims as complex claims for external medical review can save substantially on overpayment, as savings tend to scale with the size of the claim and increase further when taking into account potential reduced costs in reinsurance. Using high cost as an indicator of abuse or error and prioritizing claims for review based on costs has shown to be a continually effective stop-loss measure.

Claims that defy predictive modeling

Costs of treatment can be predicted with a good degree of accuracy by predictive modeling. Claims processors can use tools like PredictDX to understand acceptable courses of treatment and expected costs over the course of an entire diagnosis and identify when expected costs begin to deviate from actual costs.

If your system can flag claims for review based on discrepancy from expected costs of treatment for a diagnosis, you have another indicator prior to a costly review that something could be amiss and an outside review could be necessary.

Claim types with systemic overpayment

Certain types of claims, like specialty drugs processed through the medical benefit, are often chronically overpaid due to imperfections in claim processing software and a rapidly changing treatment landscape. Erring on the side of caution where you know your claims processing is the weakest and sending more of these claims for review and audit can help reduce overpayment and help you to fine-tune your adjudication process.

Claims from problematic providers

Fraud happens, and providers often know your own adjudication weaknesses better than you do. Abuse could account for as much as 10% of healthcare costs all by itself. How can healthcare payors solve what is essentially a provider-side problem? By applying a higher level of scrutiny to providers that buck payment trends (by consistently defying predictive modeling).

Medicare successfully controlled costs in this way by applying rigorous medical review and refusing to allow providers to make adjustments on claims that had been medically reviewed and denied.

Politically Sensitive Claims

A high-dollar claim or a claim of ambiguous medical necessity coming from a high level insurance decision-maker at a company can have a more significant set of consequences for denial than a more common claim. A denial of a subscriber at this level could have more costly implications for your company.

In these delicate situations, having an impartial review from an outside party could provide the political insulation necessary to adjudicate a politically sensitive claim fairly and with lower risk of repercussions.

At Advanced Medical Strategies, we pride ourselves on our physician-led medial review and claims auditing processes. Unlike other review services, every one of our medical necessity reviews is overseen by an experienced physician. With AMS you can have confidence that the claims you send us for review will be accurately and thoroughly investigated, allowing you to make confident coverage decisions. Contact us today for more information.