Medical billing errors have long been a problem that self-insured employers seek to weed out. One such effort involves payment integrity to help stem the tide of fraud, waste and abuse by implementing processes and procedures to ensure that all health claims are correctly paid. With this in mind, it's imperative for a TPA to have a robust, end-to-end solution to address these concerns, suggests Jessica Bemowski, manager of payment integrity at UMR, a United Healthcare Company. Such practices include a review of all stages within the life of a claim, ranging from pre-adjudication logic and prepayment to post-adjudication and post-payment.

In an interview, she explains that now more than ever it's imperative for self-funded employers to be aware of what they're spending their money on, noting how UMR's use of payment integrity routinely saves its customers $5 to $10 per member each month. The overriding goal is to apply cost-containment solutions as early as possible, including giving providers an opportunity to correct errors prior to routing claims through the system.

Since new schemes are always emerging, it's critically important that the TPA field a team of expert investigators who are well trained to spot and eliminate them, as well as provide a list of organizations with whom continuing education and training are provided. California, Texas and Florida are a hotbed of such activity, while air-ambulance providers have become increasingly egregious in overbilling customers. The more that a system can be automated, the more Bemowski says it will strategically free up representatives to be on the lookout for inaccurate billing.

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Bruce Shutan

Bruce Shutan is a Portland, Oregon freelance writer who has written about the employee benefits space for more than 100 publications or corporate entities for 32 of his 37 years in journalism. He also has been quoted about benefit trends in The Wall Street Journal’s interactive edition and syndicated radio program on work-life issues, Reuters and other media outlets.