Payment Integrity

Overview:

Ensuring payment integrity is a critical aspect of managing healthcare costs effectively. The complexities involved in claims processing, particularly in the NICU setting, demand a nuanced approach.

Challenges of Payment Integrity:

In healthcare, payment integrity encounters various challenges, from delayed processing times to overlooking critical claims, especially within the NICU setting. Traditional programs often take 30 days or more to process claims and are primarily focused on high-dollar claims and few programs review every claim, which leads to inaccurate payments and lost savings. It is not uncommon for health plans to use a ‘stacked’ approach to payment integrity, adding specialized solutions to identify more errors and overpayments.

ProgenyHealth’s NICU Payment Validation & Assurance (PVA) Program:

ProgenyHealth stands at the forefront of addressing NICU savings challenges through its innovative NICU Payment Validation and Assurance program. PVA seamlessly integrates NICU Utilization Management (UM) with our Baby Trax® platform. This allows us to validate coding post-claims using clinical information received from concurrent UM, eliminating the need to request additional clinical data.

ProgenyHealth’s program includes:

1. Efficient Processing: ProgenyHealth processes claims in 1 to 2 days, ensuring timely and accurate payment.
2. NICU Focus: With 100% of NICU claims reviewed, ProgenyHealth sees around 20% to 30% of NICU claims are inconsistent with authorized services or lack support from medical records.
3. Review and Validation: We validate coding post-claims using clinical information received from concurrent UM, eliminating the need to request additional clinical data.
4. Identified Savings: Payment is contingent on identified savings – no findings means no cost.