Claim Edits Libraries are Not Created Equal

By Moliehi Weitnauer and Taylor Bynum | Posted: 06/06/2017

Written by Moliehi Weitnauer, Vice President of Product Management, and Strategy, and Taylor Bynum, Product Manager

Medical claims software is a standard part of health care billing systems for large providers and physician practices. What’s not standard are the claim edits libraries these applications pull from.

Most commercial payors use publicly available code edits, including nearly a million edits published as part of the Centers for Medicare and Medicaid Services’ (CMS) National Correct Coding Initiative (NCCI). The challenge for providers is that payors also have their own proprietary rules for claim adjudication that are specific to them. And, with health care reform, providers are sending claims to an increasing number of commercial payors, creating millions of unique code pairs and further exacerbating the problem. This huge variation in payor rules – compounded by the fact that so many rules are unknown to providers – is a difficult and expensive hurdle. According to the American Medical Association (AMA), 4 to 18 percent of claim edits that result in zero dollar payments are based on undisclosed payor edits.*

Claims edits challenges:

Tackling the claim edits challenge is difficult. Health care providers who buy and install editing software themselves may not know how to manage coding release dates in their patient accounting systems and inadvertently send claims without the most current edits. Providers who choose outsourced solutions may find their vendors rely primarily on CMS’ published rules and annual printed coding books, which often means their edits are applicable to some, but not all payors. Even claim editing solutions that incorporate unique payor rules are vulnerable to incorrect interpretations resulting in claim denials or delays.

These scenarios make the claim edits library a significant factor for health care providers considering a new claims management and billing solution.

Features to look for that can help reduce errors and accelerate reimbursement include:

  • Ability to analyze claim denial data and retrofit rules based on actual payor behavior
  • Substantial library of professional and/or institutional edits
  • Edits proactively pushed to providers twice a week versus monthly or less
  • Expertise to build a claim edits database for edit combinations as well as structural edits
  • Capacity to look at all provider markets and product lines for rules applicability
  • Depth to address diverse payor requirements in all or most states
  • Advocacy for providers with payors who interpret rules incorrectly
  • Constant access to knowledge and support to quickly eradicate problems and get claims out the door

nThrive™ is one of the few claims management solution providers offering these capabilities. We go beyond periodically implementing publicly available edits and individual payor directives. We maintain a library of 28,000 edits across payors in 50 states and release updates to clients twice each week. As a result, our clients achieve an average claim rejection rate of less than 2 percent, compared to rates up to 15 percent among providers who use other solutions or manage their own edits.

Where many solutions providers act as conduits to payors, nThrive is an extension of the provider team, helping manage constant change and speed reimbursement. As an example, when a payor continually rejected a client’s claims, we went to work and discovered a rule that made claims appear clean when they weren’t. Over six months, we identified $36 million in rejections — $32 million of which should not have failed — and helped the client resolve the issue and recover the revenue. This type of expertise and personal service helped nThrive earn the #1 ranking in claims management in the 2015/2016 Best in KLAS report.

nThrive’s claim editing technology has been proven to help maximize reimbursements and prevent hospital denials. Contact a specialist to learn more.

* Standardization of a code-editing system white paper, American Medical Association, November 2011.