Medical claims audit system saves DragonPoint client nearly $500K in first year

A compliance VP at a leading medical company had an idea she knew would save her company hundreds of thousands of dollars and make medical claim auditing better for everyone. She just needed the right partner. Here’s how DragonPoint helped bring the vision to life…and save them big bucks.

Challenge

Help each of the client’s 300+ medical clinics use the most accurate procedure codes when submitting insurance claims
Shorten the time between filing the insurance claims and providing the audit results to their clinics
Bring claims audit process internal

Developed, tested and launched a browser-based solution that…

- Provided auditors with a series of questions to answer while reviewing the patient’s medical chart
- Calculated the correct procedure code based on administrative rules set up prior to the audit instead of relying on each auditor to choose the correct code
- Used a template created by a system administrator to standardize and shorten the time required to notify the doctor’s team of errors in the claims to allow correction
- Scored the various clinic locations and doctors in order to identify those that required training to improve procedure code accuracy

Results

Time between filing the insurance claims and providing the audit results to clinics went from six months to monthly or more frequently
Claims audit process was brought internal
Client was able to reduce the outside service expense by $450,000 in their first year of using the application

DragonPoint became a trusted partner for this client, and we’ve since been able to improve the application further by:

Setting the system to import data on a regular schedule from commonly used medical records applications such as Athena and NextGen
Allowing the auditor to create audit batches by setting criteria for the system
Allowing the auditor to open the patient chart while filling out the questions on the audit system, which calculates the correct procedure code as the auditor answers each set of questions
Programming the system to compare the procedure code from the claim to the calculated one and provide a score
Notifying the doctor and the clinic team of their score, ultimately working with the team to create a performance improvement plan, if required

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Medical claims audit system saves DragonPoint client nearly $500K in first year

Challenge

Solution

Results

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Custom Computer Programming

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