Medical Claim Auditing Custom Solution

Frustrated with a time-consuming, clumsy paper process? Teximus’s client requested an application to simplify and automate the process used for medical claim auditing. The purpose of an audit was to help each of the client’s 300+ medical clinics use the most accurate medical procedure codes when submitting insurance claims.

Simplifying Auditing

To help clinics implement suggestions for improvement as soon as possible, the client needed to shorten the time between filing the insurance claims and providing the audit results to their clinics. With Teximus’s help, they have now shortened this time from 6 months to monthly or more frequently. In addition, by bringing the claims audit process internal, they were able to reduce the outside service expense by $450,000 in their first year of using the application.

Making the solution browser-based.
Providing auditors with a series of standard questions that they would answer while reviewing the patient’s medical chart.
Calculating the correct procedure code based on administrative rules set up prior to the audit instead of relying on each auditor to choose the correct code.
Using a template (created by a system administrator) to standardize and shorten the time required to automatically notify the doctor’s team of errors in the claims to allow correction.
Scoring the various clinic locations and doctors in order to identify those that required training to improve procedure code accuracy.
Replace the external audit service with internal auditors.

The new application met and exceeded the client’s primary goals. As the application was developed and tested, the client recognized additional opportunities to improve the process by adding functionality to the system, including the following

Import claims data: data is automatically imported on a regular schedule from commonly used medical records applications such as Athena and NextGen.

Create Audit batches: The auditor selects the clinic and doctor being reviewed and is assigned a batch of claims, which is a sub-set of all claims imported form the source system. To create the batch, the system randomly selects the specified number of claims that meet the criteria predefined by an administrator. For example, the administrator may define these business rules for a batch: 50 claims submitted to Medicare and BlueCross with a procedure code within the range of Z11.3 – Z34.9

Review chart data: The auditor can open the patient chart in the originating EMR system concurrently with filling out the questions on the Audit system, which calculates the correct procedure code as the auditor answers each set of questions.

Score the claim: Once the audit form is completed for a specific claim, the system compares the procedure code from the claim to the calculated one and provides a score.

Notify doctor and team: once the batch of claims is completed, the auditor generates a report using the template which is emailed to the clinic team notifying them of their score, ultimately working with the team to create a performance improvement plan, if required.

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Medical Claim Auditing Custom Solution

Simplifying Auditing

The client’s primary goals for the new system included the following.

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