Blue Cross Blue Shield of North Dakota is introducing a new level of claims payment analysis on top of our existing system of checks and balances. We call the two-level system the Payment Integrity Program.
The new added level of analysis comes through a partnership with Cotiviti. It will ensure payments are correct, assigned to the right payer and consistent with national standards and guidelines.
Cotiviti’s system draws on decades of data, and its staff includes registered nurses, as well as medical and claims professionals with expertise in coding, claims operations and quality.
What’s being audited
Retrospective
- Clinical Chart Validation (CCV): This analysis-driven audit requires review of medical records and includes complex DRG (Diagnosis, Revenue codes, and Procedure codes) review (beyond just coding and documentation).
- Coordination of Benefits Validation (COB): Identifies when another carrier or entity should be responsible for paying on a claim.
- Retrospective Claims Accuracy (RCA): Most often these will be provider billing issues such as split bills and excessive units being billed.
- Contract Compliance (CC): Validates claim reimbursements in accordance with differing provider contractual terms.
Prospective
- Payment Policy Management (PPM): Uses advanced data analytics to identify claims that are at an elevated risk for incorrect coding and claim reimbursement.
- Coding Validation (CV): A process within PPM where complex claims can be briefly paused and sent for clinical review. These claims are reviewed by qualified clinical professionals who determine if these complex claims have been coded appropriately.
Timeline
We will implement the Payment Integrity Program in phases over the coming months.
- June 2022: Retrospective Fully Insured and Medicaid Expansion
- September 2022: Retrospective Self-Funded
- Q4 2022: Prospective Fully Insured and Medicaid Expansion
- Q4 2022: Prospective Self-Funded
Want more information on the Payment Integrity Program? Refer to the Provider FAQ and look out for more updates coming soon.
We appreciate your participation in our network and your dedication to the well-being of your patients.
