Payment Integrity

As employers, you encounter numerous challenges, but managing the intricacies of health insurance should not be one of them. At Blue Cross and Blue Shield of Kansas (BCBSKS), we are committed to ensuring every dollar spent on health care claims is accurate, appropriate and aligned with the terms of coverage. This allows employers to trust that health care dollars are being used effectively for both the company and its employees.

We accomplish this through payment integrity, ensuring that health care claims are paid accurately, appropriately and in compliance with contractual and regulatory requirements. It involves identifying and preventing overpayments, underpayments, fraud, waste and abuse. By combining data analytics, clinical expertise and policy knowledge, payment integrity solutions help health care organizations protect financial resources, improve operational efficiency and support fair and ethical reimbursement practices.

Impact on health care expenses

Inaccurate provider billing and deliberate fraud can have a big impact on the cost of health care for everyone. Increased automation and complexities of claim coding with thousands² of different medical billing codes often result in mistakes during claims submission.

The most common billing errors include duplicate charges, billing for canceled tests or procedures, the use of higher severity codes than is indicated by the care delivered and inaccuracies in the quantities of both supplies used and units of time.³  Not only do these billing inaccuracies lead to unnecessary costs, they also add an additional administrative burden and a negative experience for you and your employees.

That’s why it’s more important than ever for your health insurer to have rigorous processes and systems in place that help mitigate claims processing and reduce avoidable spending.

Our commitment

Nationally and locally, our mission for payment integrity is to safeguard health care expenditures from accidental and intentional billing and coding errors.

To identify and correct provider billing errors, Blue Cross and Blue Shield companies are required to perform the following ongoing activities:

• Adhering to contract compliance
• Claims code editing
• Itemized bill review of all claims of $100k or more
• Comprehensive reviews and audits include fraud, waste and abuse investigations and credit balance reviews
• Accurately coordinating benefits when a member is covered by multiple health plans
• Provider outreach and education

Evolving Capabilities

At BCBSKS, we are evaluating historical billing patterns and applying intelligent data processing on our proprietary claims data. We are continuously enhancing our detection capabilities, particularly in pre-payment to catch errors before a claim is paid. We also look at industry trends, tapping into our unmatched local market knowledge. By leveraging partnerships with vendors offering complementary expertise, we can continue to uncover further billing and coding inaccuracies, strengthening our payment integrity solutions.

Provider Support

Because BCBSKS has longstanding relationships with our network providers, we’re best positioned to educate them about the importance of compliant coding and billing accuracy. We routinely meet with our provider partners across Kansas to share insights and data to keep them informed and help improve their performance. We offer resources for proper claim coding, compliance standards, fraud, waste and abuse.

In addition, by holding providers accountable and tracking the rate at which billing errors occur, we’re able to identify providers in need of additional training and support. This creates more personalized, targeted intervention with those specific providers helping to mitigate future errors. When needed, provider contract changes are made to ensure continued adherence.

Conclusion

At BCBSKS we’re dedicated to protecting your bottom line by identifying and eliminating unnecessary costs. Backed by advanced analytics and a team of specialized payment integrity experts — including certified coders, clinical review nurses, and pharmacy professionals — we work to safeguard your healthcare spend through ethical billing and reimbursement practices.