Healthcare is a human business. And as we look to modernize the healthcare financial experience, it’s important to keep in mind that the core of the healthcare journey is the patient and their unique story. But what does a health plan do when those unique stories show up on a claim without a clinical policy to guide claim reimbursement?

To shed light on this critical issue, I had the privilege of sitting down with Summer Stout, Zelis Director of Client and Clinical Coding Policy and Registered Nurse, to delve into the strategies for navigating these clinical gray areas where coding policies may not yet exist to support claim reimbursement.

Turn complexity into action

The healthcare industry is a vast and complicated network of providers, payers, and patients, each with their own needs, challenges, and requirements. As a result, there are countless opportunities for errors, discrepancies, and inconsistencies to arise in the payment process. These errors can lead to overpayments, underpayments, or even no payments at all, creating financial strain for providers and payers alike.

The saving grace? Policies and guidelines. But when a clinical coding policy or association guideline doesn’t exist to support the reimbursement billed on a claim, these are called clinical gray areas, and that’s where the problems really start.

When claims fall into the clinical gray area without an established policy or guideline to support edit recommendations or adjustments, they often end up paid in full without so much as a second glance. Unfortunately, this practice contributes to higher costs, negatively impacting members in the long run.

But according to Summer, “this void creates an opportunity.”

Technology investments in machine learning (ML) and aritificial intelligence (AI) allow organizations to analyze vast amounts of data quickly and accurately, identifying potential errors, discrepancies, or anomalies in the payment process. By using these tools, organizations can identify and address payment issues more quickly, reducing the risk of financial loss and ensuring that providers are paid accurately and fairly for the care they provide.

However, this shift towards automation can often leave the human aspect of healthcare behind. Meaning: those clinical gray areas will continue to be a problem.

By incorporating human expertise to conduct thorough claims reviews for these gray area cases, like Summer mentions, we have an opportunity, or more specifically, we have the potential to drive effective solutions and enhance payment accuracy.

That’s why when looking for a vendor solution, it’s vital to find one that focuses on the “gray areas” in healthcare where policies and guidelines are often absent and where the human element of care comes into play.

Clinical gray areas: a deep dive

Clinical gray areas refer to situations or medical cases where there is ambiguity or uncertainty regarding the most appropriate course of action, treatment, or diagnosis. These are scenarios where existing clinical policies, guidelines, or standard protocols may not provide clear direction or are inadequate to address the specific circumstances.

This may be due to a number of reasons, including, but not limited to:

  • Rare or unique conditions
  • Emerging treatments
  • Off-label use of medications
  • Complex cases
  • Interdisciplinary situations
  • Varied clinical opinions

In other words, with claims editing, you have a world of “yes – no” logic. This is what drives reviews and workflows. Clinical gray areas refer to the space where a “yes” or “no” rule doesn’t apply.

I’ll let Summer explain.

“In the absence of an existing policy, guideline, or societal rule that drives the “yes – no” claims editing logic, taking a comprehensive look at the claim and medical documentation to determine appropriateness of treatment goes beyond standard claims edit logic.”

An example would be the trend of upcoding chiropractic claims. Some payers don’t have chiropractic clinical policies, or, if they do, they don’t have the bandwidth to enforce them. This is where partnering with a vendor can really help.

But it’s not all one size fits all. You need a partner with a strong team that truly understands the ins and outs of coding, medical documentation, and overarching policies. For instance, in the example above, your vendor’s team could use their expertise to develop a chiropractic coding policy that you can then leverage.

Amp up collaboration

Another key factor in maintaining payment integrity is collaboration between payers and providers. Historically, payers and providers have been at odds when it comes to payment, with each side often seeking to maximize their own financial gain.

However, as the healthcare industry has evolved, there has been a growing recognition of the need for collaboration and partnership between payers and providers to achieve better outcomes for patients and the system as a whole.

It’s the same for payers and vendors.

“Collaboration is a key component of developing enforceable and sustainable clinical coding policies.”

As such, you need a vendor solution that comes with a team of clinical coders, nurses, fraud, waste, and abuse experts, as well as clinical data analysts who monitor trends and claims volume, legislative and association guidelines, denials, and so much more to stay abreast of coding policy areas where recommendations are lagging.

But that’s not all. Your vendor partner should leverage your team’s depth and expertise for each reviewed claim and supporting documentation, going above and beyond to actively support your organization and walk you through the review process, managing any disputes that arise and providing provider education when needed.

Go beyond laws and regulations

Another key factor in maintaining payment integrity is compliance with applicable laws and regulations. The healthcare industry is heavily regulated, with numerous federal and state laws governing the payment process. Failure to comply with these laws can result in significant financial penalties, as well as reputational damage for organizations.

To stay compliant, healthcare organizations must stay up-to-date with the latest regulations and guidelines, and implement robust compliance programs that ensure adherence to these standards. This includes investing in training and education for staff members, as well as implementing effective monitoring and auditing processes to identify potential compliance issues before they become a problem.

You need a vendor solution that dives into opportunities and trends daily, staying abreast of the changes in healthcare in real-time.

For example, the first COVID-19 ICD-10 code was released on April 1, 2020, nearly three months after the virus first appeared in the U.S. You need a vendor team that can dive into these opportunities and trends daily to see where edits don’t exist. This allows you to be informed of trends as they happen, rather than adjusting to them months later.

The wrap up

Payment integrity is a critical factor in managing costs and ensuring fair and accurate payment in the healthcare industry. And while it may seem that clinical coding policy is all about denying incorrectly, it’s actually more about stopping inappropriate payments before they happen without impact to prompt-payment guidelines. Meaning: you can now go beyond the status quo of payment integrity, bringing a deeper level of expertise and analysis to find more areas of clinical waste and savings.

To see how Zelis is providing clients with an added layer of expertise and analysis that helps to ensure that patients receive the care they need while reducing clinical gray areas, minimizing waste, and reducing costs, connect with us on LinkedIn:

Bonnie Coburn, Vice President – Product, Claims Editing

Summer Stout, RN, BSN – Director of Client and Clinical Coding Policy