The Payment Integrity Process: A Step-by-Step Guide

Payment integrity plays an important part in healthcare cost containment solutions. Many employers have found that implementing proper payment integrity strategies can result in big savings.

It’s no surprise that companies are exploring such savings methods, as prices are expected to rise by an average of up to 5% in 2022. Employers understand the importance of providing quality healthcare access that’s also affordable for their employees. Not only does healthcare play a major role in employee retention and company recruitment, but it also exerts a powerful influence on employees’ professional choices. Half of Americans cite healthcare as an important factor in deciding whether to remain at a current job or accept a new one.

Healthy Employees = Good Business

What’s troubling is that only 51% of employees are satisfied with their employer-sponsored healthcare, according to a survey by the Employee Benefit Research Institute. A major point of contention is the cost of healthcare coverage. According to the survey, one in three employees experienced increased healthcare costs during 2021. 

Paul Fronstin, director of EBRI’s Health Research and Education Program said that as a result of the increases, employees “have experienced a variety of impacts, including increasing contributions to HSAs, decreasing contributions to their retirement plan, delaying going to the doctor, increasing credit card debt, or using up all or most of their savings.”

Helping employees manage the cost and quality of their care can be a mutually beneficial path that ensures their well-being and gives them the resources to be productive. Payment integrity can make affordable healthcare a reality by scrutinizing the billing practices of providers to ensure patients are not overcharged.

Understanding how the payment integrity process works is just as significant as implementing it. Luckily, this blog post breaks down the process for you into a step-by-step guide. 

Payment Integrity Process

The payment integrity process is surprisingly simple. It can help keep healthcare reimbursement free from hiccups and improve efficiency for the entire process. 

In part, the goal of payment integrity is to bring about increased transparency in healthcare reimbursement. Because the elaborate billing process has been purposefully vague for such a long time, knowing the dynamics behind it can be beneficial. First, you should know that payment integrity occurs primarily during the pre-payment stage. The post-payment stage involves Diagnosis-Related Group (DRG) validation, hospital bill audits, pharmacy and implants review, data mining, and medical necessity.

Pre-payment 

True payment integrity occurs before a patient pays any charges. This typically involves itemized bill reviews as well as DRG validation to verify the proper medical codes are used. Starting from the pre-payment stage allows clients to settle bills upfront, rather than the traditional “pay and fight” option. 

Because payment integrity often includes a detailed review of line-item claim data to identify errors or inconsistencies that would have been paid by a patient, it requires a few different steps to guarantee accuracy:

Claim Receipt

Once the claim and all related documentation are received, the client sends it to a third-party administrator (TPA) for initial review. This review determines if the claim warrants an in-depth, clinical review. After approval, the claim moves on to the clinical review stage.

Clinical Review

During the review stage, clinical experts will go over the bill with a fine-toothed comb to ensure there are no inconsistencies or billing errors the patient is being asked to pay. Within the practice of payment integrity, the clinical review stage makes up the bulk of the process—where savings are created. This typically takes about five to seven business days. After completion, the claim review is sent to the provider.

Provider Review

During this stage, the charges on the bill will be negotiated based on the clinical review’s findings. The provider will be expected to accept the restructured bill and depending on their response, one of two things will occur:

1. Resolution

The provider accepts the new charges and agrees to pay them with no issues.

2. Formal Appeal

If the provider disputes the findings of the clinical review, an appeal will be filed and the claim process will go back to the clinical review stage. 

As you can see, payment integrity is far from intimidating and its streamlined nature ensures that the process is swift and efficient.

6 Degrees Health for Payment Integrity

6 Degrees Health was founded with the intention of bringing integrity and transparency to the healthcare reimbursement process, which continues to see costs balloon exponentially. Our unique Clean Claim Reviews process goes beyond a typical clinical review by examining every line item billed. 

Our payment integrity process removes charges before the network discount is applied, eliminates balance billing, and manages appeals and support after payment—and all of this is in addition to the guaranteed savings.

Interested in learning more about the payment integrity process? Speak to a representative today to learn how to submit a claim for review so we can help you realize the true benefits of healthcare.