I have been asked many times in my 16-year career in claims auditing about the software that we utilize to perform our work. The fact is that it is easier to understand our job as a black box program that spits out errors than one which requires constant time, attention and especially judgment from a professional.
Some audit vendors have chosen to explain their work by naming a software that they use for audits, but we do not believe that correctly communicates the real value that clients get in working with JGI. The best way to understand why claims auditing is not a software solution is to imagine what it would take for that software to work. First and foremost, it would mean that someone was able to code edits that worked across different claims payers, platforms and benefit plans to find errors. If such edits could be coded in an audit program, then they could be coded in claims payment platforms as well.
Most major national carriers process both fully-insured and self-insured claims on the same platform, meaning that such edits would hold great value to reducing costs on at-risk money for these carriers. So, if such edits could be coded, every claims payer in the country would utilize (buy) them for their own claims platform to stop overpayments from happening in the first place!
If edits cannot be coded in this manner, then what is the role of technology in the claims audit? Simply put, database platforms and associated algorithms allow a claims audit professional to apply his or her expertise and professional judgment across a large data set systematically rather than by hand. Queries are used to focus on key trends, to isolate certain types of claims, or to eliminate large swaths of false positives. The results across the board though are still not validated errors – they simply point to potential issues. The key is the claims audit professional who sifts through this output and makes judgment calls about the claims. No expertise, no claims audit. A software might sound good for marketing, but the real value of a claims audit lies within the professionals delivering it.
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