Case Study
Preventing Fraud, Waste, & Abuse in Medical Records
Challenge
As part of their review of healthcare payer claim payments, Payment Integrity (“PI”) companies often work with disorganized Medical Record (“MR”) files, delivered in .pdf format, physical paper documents, or fax transmission, varying in volume between several hundred to 2,400+ pages. The inconsistent delivery formats and lack of organization in these files pose significant time challenges for the medical professionals employed by the PI firms.
Healthcare providers are often reluctant to undergo the level of scrutiny that the PI firms will apply as they review medical claims for instances of fraud, waste, and abuse (“F/W/A”). In an effort to discourage those reviews, healthcare providers may provide the patient’s electronic health record in a paper or fax format, and / or shuffle the file to make finding relevant information more difficult. As a result, the PI reviewers often end up spending excessive time organizing and sifting through these records to identify specific pieces of information that will substantiate their F/W/A findings. If the MR files were pre-categorized by document type, organized with a table of contents, and equipped with searchable functionality, PI reviewers could work more efficiently, enabling them to review more claims in less time, ultimately saving the healthcare payers and their members more money.
Industry
Insurance/Healthcare
Data Type
.pdf Files
Project Duration
Ongoing?
No
Solution
With a thorough understanding of our client’s needs and a clear vision of what the outcome could yield, we went beyond merely reorganizing medical record files; we tailored them to meet our client’s specific needs. Therefore, we:
- Categorized the records to facilitate the workflow of their medical auditors
- Captured the Date-Of-Service (“DOS”) details from each page
- Arranged the documents in DOS chronological order
- Tagged each document with provider information to enable rapid searches by provider name
- Provided search functionality and a table of contents, which allows key information to be easily and quickly located
Outcome
DataInFormation’s solution reduced MR search time, which empowered our client’s medical professionals to reclaim a significant amount of time for discovering and substantiating instances of F/W/A, instead of paging through hundreds of unsorted documents. By saving each reviewer 25% or more of their time, they increased the number of MR files they review each week. This in turn enabled our Payment Integrity client to examine a higher volume of claims, which directly drives revenue.
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