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03:35 PM
Thomas Schutz, Experian QAS North America
Thomas Schutz, Experian QAS North America

Streamlining the Health Insurance Compliance Process

Health insurers must be careful when allocating government funds toward any claim. Misrouted claims leave carriers at risk for fines and even charges of fraud.

As we learned this week, health insurance regulation can be fluid. Currently, most insurers manually research each claim to determine which party is responsible for paying – the insurer, the patient, or the government. In order to determine the payer, health insurers review each case individually and reference government exclusion lists. Each exclusion list identifies a set of physicians or individuals that must be excluded from government funding. The Department of Health and Human Services (HSS) and The Centers for Medicare and Medicaid Services (CMS), for example, maintain a variety of these lists. The lists include the Office of Inspector General’s (OIG) LEIE database, the General Services Administration’s (GSA) Excluded Parties List System (EPLS), and Medicare & Medicaid opt-out lists. While each list has a unique focus, they all share one common characteristic. A physician that appears on one of these lists may be ineligible for participation in some, or all, government healthcare programs. With this in mind, health insurers must be careful when allocating government funds toward any claim. Misrouted claims leave carriers at risk for fines and even charges of fraud. Checking these lists can be a very manual process that drains resources, decreases staff productivity and affects patient payouts. But when corporate compliance is on the line, organizations know they need to ensure the accuracy of each claim. However, the manual work may not be as accurate as insurers believe. Relying heavily on manual processes leaves insurers vulnerable to human error. According to a recent Experian QAS survey, human error is the main cause for data quality errors. When dealing with compliance processes, a staff member could forget to check every relevant exclusion list or could mistype the physician’s name, leading to erroneous results. To ease the burden of compliance, insurers need to look for an automated method that can speed up the search process and alleviate the risk of human error. There are several factors that insurers should consider when selecting a vendor:

  • Look for a vendor that incorporates sophisticated matching. Even with software tools, staff still need to type in information to search against these lists. Sophisticated matching can be utilized that will increase the likelihood of finding a match, even if the record is missing words or contains spelling errors, nicknames or prefixes.

  • Work with a software-as-a-service solution. If lists are not updated on a frequent basis, insurers can become prone to non-compliance. Insurers should find a vendor that will take on this task on their behalf so they do not need to worry about updates. Having an online service vendor will help that ensure organizations are using the most up-to-date information possible.

  • Ensure tools have a centralized look-up source. By providing one master repository, staff members can save time and not have to worry about searching against multiple sources.

  • Use a vendor that provides proof of validation. The proof of validation ensures the accuracy of records and reports are available for future audits.
To automate the compliance process, insurers need to roll-out a sophisticated solution that works within the existing workflow. An automated solution for health insurers will make certain that the organization processes claims correctly, but even improves efficiency.

About the author: Thomas Schutz is SVP and GM for Experian QAS North America, serving as the company's top executive for all strategic business decisions in the United States and Canada. He be reached at [email protected].

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