Cut Fraud, Waste, & Abuse on Claims with CMS-Issued Clinical Edits
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Improperly billed payments are a significant issue in the healthcare industry. There’s a big difference between fraud and abuse, but the result is the same: waste. In 2019, ranges of total annual costs specific to fraud and abuse were estimated between $58.5 billion to $83.9 billion.¹ The scale of this problem demands that conscientious payers take action and implement preventative solutions to eliminate fraud, waste, and abuse. While most plans do take action to address these issues, the success of their efforts depends on the tools they have available. Many healthcare payers still rely on manual review, spreadsheets, and legacy solutions that cannot effectively cover the range of possibilities that a modern system supports.
Enter Beacon’s focus on claims and payment integrity: Compass Code Edits. Our clinical code editing solution provides control over fraud, waste, and abuse while streamlining all processes related to claims management. Using over 4.2 million federal-approved and industry-sourced edits, Compass scrubs claims for inaccuracies, unlikely amounts and charges, mutually contradictory code usage, code validity, and time-sensitive edits which ensures that pre- and post-operative care that should be included in surgery payments are not billed separately. Together, this improves payment accuracy and reduces unnecessary medical costs with clinically-supported claims analysis and rationales, all without any disruptions to your current workflows.
Compass can be deployed alongside your existing legacy claims system
for minimal disruption to your current processes.
Compass will work with your existing trading partners’ files and add mutually agreeable adjudication codes that your legacy system can use to automatically deny improperly billed service lines. Compass can work in tandem with just about any of your existing pre-adjudication or pre-payment integrations, such as the original intake of the 837 or proprietary claim file, network repricing, cost-containment, negotiations, and other payment integrity vendors, adding robust clinical code editing to your current business model with low implementation costs. In this model, Compass can further provide help, in conjunction with HIPAA Director, by adding sophisticated, customizable criteria for provider matching and building claim history for enhanced duplicate checking. However, the solution shines brightest when you use SpyGlass as your claims processing system. That’s when claims history and eligibility integration begin to pay off.
Compass is more than just a behind-the-scenes solution to make sure health plans are paying claims appropriately. Compass helps to get in front of potential issues before a claim is paid, as this is your most effective leverage point to provide accurate payment. Beacon’s solution moves seamlessly across the entire claim life-cycle, without human intervention or disruption to payments or providers.
5 Reasons Compass Stands Out
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Bulletproof Rationales
Based on edits published by the Center for Medicare and Medicaid Services and developed in conjunction with the American Medical Association, providers recognize the validity of Compass Code Edits.
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Logical, Fast & Accurate Results
Beacon uses enterprise-level, automated clinical code editing technology, combined with additional proprietary code-related parameters to cross-reference eligibility history, claim history, and the incoming current claim data to enable faster processing with increased accuracy.
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Expanded Savings
If you are already using an existing clinical code editing solution, you could be substantially overpaying for it. Compass is rated at about half the cost of traditional code editing vendors. Realize medical and administrative cost savings and increase end-to-end efficiency by preventing inaccurate claims and avoiding improper costs with sensibility, consistency, and accuracy.
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Flexible Offering
Payers may find themselves locked into only one option for pricing with their current claims editing vendor. We don't tell you how Compass can work for you. You tell us how you want the solution to work. We offer Compass with percent of savings or per claim transaction models with size-sensitive, reasonably scaled pricing.
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Streamlined Adjudication
All of these sourced guidelines mean nothing to your claims payment efficiency without the ability to configure our solution to fit your business model. When used in conjunction with SpyGlass, controls are available for users to design and implement procedures within your smart workflow queues to automatically pend or deny claims flagged by Compass to the appropriate department for review.
Health care fraud, waste, and abuse demand serious and strategic solutions. Your success affects your reputation, as well as the bottom-line costs for employers and their employees. Claims and payment integrity require value, experience, scalability, and innovation. Beacon has spent over two decades crafting our fully cloud-based solutions to drive value for our clients all along the claim life cycle. Compass Code Edits allows for targeted, successful claims auditing, ensuring plans make the best use of their resources to get members the care they need. Our fast, accurate results provide measurable value in increased claim auto-adjudication rates and savings on affected claims.
Enhance your claims adjudication process with Compass Code Edits by adding increased accuracy and appropriateness checks for claims before any payments are made. If changing your claims system is too disruptive, talk with Beacon to learn how Compass can enhance your existing processes.
1. Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019;322(15):1501–1509. doi:10.1001/jama.2019.13978
Ready to Learn More?
Download our Compass Code Edits product brochure today to learn how Compass can enhance your claims adjudication process by adding increased accuracy and appropriateness checks for claims.
