1 . |
Out-of-Network (OON) Claims Negotiation |
|
Each day EPOCH’s claim system looks for non-network claims (over $100 claim). EPOCH attempts negotiation by sending them electronically to outside networks. EPOCH has contracts with two different preferred provider organizations for OON claims. If we are not able to get a discount through the client’s primary network we will electronically forward the claim to the 1st OON PPO. If we are unable to obtain a discount there, we will send on to the second PPO.
The following are EPOCH’s results:
• 60% of all claims are between $100 and $499
• 15% of savings are between $100-$499
• 15% average OON discount on 75%-80% of OON claims
After the claim is adjudicated and sent for OON negotiation, the claim file is forwarded to the check cycle. The accounting functions are completed (notifying client of the funding requirement, etc) and the checks are mailed out.
|
2. |
Bill Audit |
|
EPOCH offers retrospective bill review through our external partner. Post pay audits are routinely performed on non-network hospital claims exceeding $10,000 where one or more of the following criteria are met:
• EPOCH was not able to negotiate a reduced fee internally or through our external partners
• Supply charges exceed 50% of the total billed charges
• Total ancillary charges exceed 40% of total billed charges
• Charges for implantable devices exceed $15,000
• Pharmacy charges exceed 50% of total billed charges |
|
|
3. |
Fraud & Abuse Investigation |
|
EPOCH has system edits that trigger the review of claims that are questionable for diagnosis as well as treatment type. Once a flag has been triggered, a letter is generated to the physician and/or member to submit appropriate documentation for the necessity. After the information is received, the claim is forwarded to our medical review desk for determination. If the information is questionable, we forward the documentation to our medical director for review.
In addition to the RIMs system edits and manual examiner intervention, EPOCH also contracts with an external vendor to detect fraud and abuse. Claims are sent nightly through a software program that uses dynamic profiling and predictive modeling to identify fraudulent claims and providers. This system includes dynamic profiles that define behavior patterns describing how each entity in the process behaves and interacts.
Sophisticated models, analytics and outlier detection processes convert selected data into real-time actionable results. This practice results in fraud scores that target suspect providers so that claims may be flagged for suspected fraudulent billing patterns. |
|
|
4. |
Claim Subrogation |
| |
Any claim document with a specific reference to worker’s compensation, third party liability, or a motor vehicle accident is investigated. In addition, a decision matrix by ICD-9 diagnosis code is used by examiners to determine when an accident investigation is required. Any claim with a diagnosis on the investigation matrix must be investigated once claims reach $1,000.
If an investigation is needed, a subrogation questionnaire and reimbursement agreement is sent to the member requesting specific details of the incident, a police report, insurance companies, any third parties, attorney information, and other payment or settlement information.
All potential subrogation cases are reviewed and the status is maintained in the Quality Assurance Department. Subrogation recovery is outsourced to our external partner once the appropriate Service Agreement is executed.
|