Cracking The Codes
Written By Bruce Shutan
Payment-integrity services evolve as tool to help self-insured health plans weed out fraud, waste and abuse
It’s almost hard to fathom that an estimated 25% of $4.1 trillion in U.S. health care spending has been traced to fraud, waste and abuse. In some cases, overcharging for medical services represent egregious attempts to capitalize on a woeful lack of transparency and misaligned incentives that the Consolidated Appropriations Act (CAA) seeks to correct. Other instances involve revenue-cycle management at its most creative or honest medical-coding errors.
In response to all these activities, self-insured employers, along with their brokers, third-party administrators and other partners, have turned to so-called payment- integrity (PI) solutions designed to end substantial leakages in such transactions and ensure that health care claims are correctly paid.
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