Helping to ensure greater claims accuracy
Putting the right checks and balances in place at each stage of a claim’s lifecycle is designed to protect employees’ dollars and lower costs for employers.
A study published by The Journal of the American Medical Association (JAMA) found that 25% of health care spending was identified as wasteful or unnecessary due to failure of care delivery or care coordination, overtreatment or low-value care, pricing failure, administrative complexity or fraud and abuse.1
Payment integrity is about working to process claims accurately — so employers and their employees are only paying for care or services rendered. Working with a carrier that has a strong payment integrity solution in place can help safeguard costs for both the employer and employees. But not all payment integrity programs work the same. That’s why employers should understand the different solutions available to them, including proof of potential savings and how a carrier’s payment integrity program compares to others in the market.
For example, UnitedHealthcare ultimately pays 98% of all claims received for eligible members when they are submitted in a timely manner, do not contain missing or incorrect information and are not duplicate submissions.2 These claims are administered through a series of checks and balances to help ensure their accuracy.
The UnitedHealthcare Payment Integrity program flagged 49.6M transactions out of 250M+ processed claims, saving employers a combined $6.8B.2 This included $4.9M from correcting billing and coding mistakes after claims were submitted during the pre-payment phase and $1.9B from resolving payment errors after claims were paid during the post-payment phase.3
At its core, payment integrity is designed to hold providers and carriers accountable to the accurate submission, processing and payment of claims. The goal is to process claims accurately, which may help reduce frustrating experiences for employers and employees, as well as uncover potential savings that may not have otherwise been realized.
How UnitedHealthcare Payment Integrity solutions work
UnitedHealthcare Payment Integrity solutions proactively work to help lower the total cost of care for employers by reducing payment errors. Payment integrity works to help ensure that health claims are paid by the responsible party, using an end-to-end approach across all 3 phases of the claim cycle. Using this methodology, employers see an average of $30–$35 savings per member per month (PMPM).3
Phase 1: Pre-Claim
In the pre-claim stage, before providers even submit claims, they are educated about how to price bills accurately and directed to the UnitedHealthcare provider communication portal to review for accuracy. The goal of the pre-claim phase is to correct any mistakes before a claim is even submitted for payment.
Phase 2: Pre-pay
After a claim is submitted but before a payment is issued, billing and coding mistakes are corrected through proactive monitoring to help reduce administrative costs and help prevent incorrect claims from entering the system in the first place. This phase helps avoid over- or under-payment and the potential for costly and time-consuming corrections during the recovery stage.
Phase 3: Post-pay
If a payment is made in error, a retrospective effort including data mining and review is conducted to help understand why the error occurred, streamline the resolution process and reduce recovery turnaround time.
Additionally, self-funded employers may be eligible for a lite or enhanced Coordination of Benefits (COB) program, which may help uncover even more cost-saving opportunities. The enhanced COB program, for instance, features both pre-pay and post-pay analytics to identify other insurance, ensuring that potential secondary coverage is detected before and after claims are processed. Pre-pay investigations review members who are likely to have COB and set flags prior to the payment of claims, helping to prevent unnecessary payments. If a flag is set after claims have been paid, the recovery team will seek reimbursement from the primary carrier to correct the payment and ensure proper financial management. Employers using this program have seen an average savings of $3.65 PMPM.4
UnitedHealthcare Payment Integrity solutions drive savings for employers and employees
1.5-3.8%
higher total cost of care savings5
A survey of providers and carriers conducted by ZS Associates found that UnitedHealthcare Payment Integrity solutions were the “most thorough” in the industry and drove 1.5%–3.8% higher total cost of care savings than other top national insurance carriers.5
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