Payment Integrity Program

BCBSND is enhancing our core claims processing with the Payment Integrity Program. The program will enhance current capabilities to ensure payments are correct, assigned to the right payer and consistent with national standards and guidelines.

We have partnered with Cotiviti, a leading health care analytics company, to bring a new level of accuracy to claims processing. This new enhanced level will supplement our core in-house system of robust checks and balances.

A two-level strategy for accuracy

The Payment Integrity Program implements a robust Retrospective (post-pay) and Prospective (prepay) analysis of claims.

Retrospective (post-pay)

More information to come.

  • Clinical Chart Validation (CCV): This is an analysis-driven audit requiring review of medical records and includes complex DRG (diagnosis, revenue codes and procedure codes) review (beyond just coding and documentation).
  • COB 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.

Prospective (pre-pay)

More information will come on Prospective in Q4 of 2022.

  • 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.

Enhanced Payment Integrity Program Frequently Asked Questions (FAQ)