Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

On November 16, 2021, Zelis Vice President of Health Plan Sales Emily Farrell sat down with Cindy Major, Director of Claims at Cox HealthPlans, and Amy Anzola, Vice President at Zelis, RN and certified coder, to explore how specific trends in the marketplace are driving increased utilization and high dollar claims, how a strong alignment between payer and bill review partner can increase savings, and how Cox HealthPlans identified their problem and implemented pre-payment Bill Review to augment savings.

We’ll discuss the highlights below.

Today’s Market Opportunity

Healthcare is getting more expensive. But you already knew that.

What you didn’t know? Over the past five years, claims over the $100K threshold have steadily increased, with claims in the $250K – $499K range growing even quicker. Meaning: there is now a large opportunity for health plans to switch their focus to cost control.

Mainly, this opportunity lies within experimental treatments, particularly those that aren’t FDA approved and don’t meet medical necessity (think: utilizing robotics for assisting surgeries).

Moreover, as we come out of the COVID-19 pandemic, there will be an increase in previously deferred procedures.​ In fact, a study released by PricewaterhouseCoopers earlier this year identified that the results of the COVID-19 pandemic will directly lead to higher acuity care in 2022.

This is due, in part, to two main trends.

1. Deferred care.

Those who deferred care during the pandemic are now resuming their pre-scheduled procedures. At the peak of the pandemic, many hospitals canceled elective procedures to allow more access to inpatient facilities and staff.

2. Healthcare utilization and acuity.

But elective procedures weren’t the only types of care deferred during the pandemic. For a variety of reasons, many patients did not continue their routine and/or annual screenings. So what we’re seeing now is that the patients, particularly those labeled as high-risk, who are resuming these preventative screenings now require a higher rate of intervention.

As such, many healthcare organizations are experiencing a higher level of healthcare utilization with more progressed and costly diagnosis, leading to higher dollar claims.

The Proof: Cox HealthPlans Case Study

The problem.

A subsidiary of CoxHealth, Cox HealthPlans, based in Springfield, Missouri, covers a 26 county area and represents over 42K lives. Since 2016, Cox HealthPlans has seen a steady increase in high dollar claims. And with that increase in claim volume, they also experienced an increase in coding and billing errors.

In order to mitigate such growing risks, Cox HealthPlans rolled out some protections.

Cox HealthPlans utilizes both a Primary Network and a Wrap Network. And while their Primary Network covers 26 counties, they still leverage their First Health partnership when a member receives outside care. Meaning: when a Cox HealthPlans member receives out of network care, First Health reprices the claims and identifies savings through their network contracts.

They also have a claims editing workflow for claims once they are submitted. This workflow attempts to find and identify claims billing and coding errors.

But these protections just weren’t enough.

Cox was still concerned about their growing financial risks, especially regarding errors in billing and charge increases.​

The solution.

Cox HealthPlans selected Zelis as their Hospital Bill Review partner in 2016.

In order to customize the solution to best suit their goals and workflows, the Zelis team:​

  • Leveraged existing partnerships with Cox HealthPlans’ adjudicator, Cognizant, to build customizations with their QNXT denials and formatted reconciliation processes.​
  • Established strict review timeframes and full documentation protocols to adhere to timely review policies. ​
  • Provided transparency and reporting via an online Client Portal.​

Throughout the process, they learned:

  1. As processes matured, contract limitations by primary networks excluded certain claims that were sent early in the process.
  2. Zelis review ensures due diligence is performed on each claim that meets the criteria we established.
  3. Zelis accommodates specific requests related to the formatting of the recommendation and how the denials are explained on said recommendation.

To get started, they established a threshold of $25K. Any professional or institutional claims that exceeded the minimum were routed to the Zelis Hospital Bill Review team for review (including any repriced claims from First Health).

As Cox HealthPlans grew more confident in their review of claims, specifically regarding provider abrasion, they also grew more confident that their brand would be well represented through the rest of the review process.

In 2021, Zelis Hospital Bill Review is on track to help ​Cox HealthPlans save over $1.8M. Broken down, that’s an average savings of around $9.5K per claim.

Getting Started

Luckily, Zelis’ Hospital Bill Review product is specifically positioned to target these high cost treatments. Our team of experienced nurses, physicians, and certified coders review inpatient and outpatient medical claims using both itemized bill and clinical chart review with a full-scope clinical and financial analysis to ensure claim payment accuracy.

The Hospital Bill Review solution is the combination of technology, coding, and clinical expertise. The three solution sets are as follows:

Itemized Bill Review

  • Detailed review of itemized bills to identify areas of erroneous billing​
  • Errors identified may include duplicate charges, unbundling, incidental supplies, etc.
  • Adherence to industry standard coding billing guidelines and CMS

Clinical Chart Review

  • Clinical review of medical record conducted by team of clinicians​
  • Reviews include a robust audit of complex claims ensuring clinical accuracy of billed charges​
  • Specialty niche claims such as Specialty Rx, Implants, and Air Ambulance

Diagnosis Review Group (DRG) Validation

  • Review all components that impact reimbursement to ensure pertinent diagnoses were billed appropriately; supported in the medical record and billed according to official coding guidelines​
  • Based on DRG review and validation, will recommend DRG regrouping and reclassification

Each solution ensures the high dollar claim above the identified threshold you set is reviewed with care and expertise. Pre-payment completion ensures accuracy of payment and reduces the amount of time and expense it takes to clawback any overpaid claims.

The Wrap Up

As you can read, we covered quite a bit of information during the webinar. If you’re interested in finding out more about how you can experience more savings on high-dollar claims with prepayment bill review, here are some resources to get you started.