In today’s healthcare landscape, the relationship between payers and providers is often strained by administrative complexity, payment delays and disputes. At the heart of these challenges lies the concept of provider abrasion — the friction that arises from claim denials, appeals and convoluted billing processes.
But what if we could reduce this abrasion before it even begins?
The power of accurate prepayment claim edits and reviews
Accurate prepayment claim reviews and edits are transforming how healthcare payers and providers operate, and Zelis has been at the forefront of prepay for years.There is always a case for retrospective reviews, but research from leading firms like KLAS and Gartner over the past two years indicate payers are shifting resources to proactive efforts. The shift towards the left to pre-pay proves health plans are prioritizing accuracy before payments are made – which delivers benefits across the healthcare ecosystem.
For healthcare payers, the benefits are obvious:
- Cost avoidance: Prepayment reviews prevent inappropriate payments, eliminating the costly “pay and chase” cycle of recovering overpayments.
- Improved financial performance: Fewer errors and unnecessary payments mean better control of expenditures and potentially lower premiums.
- Enhanced compliance: Accurate reviews ensure adherence to complex regulations, reducing the risk of penalties and legal action.
But what about providers? Well, they benefit also:
- Faster, more reliable reimbursement: Real-time feedback enables quick error correction, speeding up payments and improving cash flow.
- Reduced administrative burden: Catching errors early minimizes post-payment corrections, audits, and documentation requests.
- Educational insights: Data-driven feedback helps providers understand and correct recurring coding errors.
Metrics that matter
New edits can create some initial abrasion, but with education and maturity, we have found that Zelis clients utilize 16 percent more recommended edits while disputes drop over 25 percent in the first two years.*
Our clients’ average dispute rates* demonstrate this:
- Claims editing (general): 0–5%
- Coding validation / clinical coding policy / genetics: 5-10%
- Clinical chart review / dialysis: 0-5%
- Itemized bill review / DRG validation: 5-10%
More importantly, edit and review sustainability rates exceed 95 percent. This means that the original edit or review determination is upheld more than 95 times out of 100, thus speaking to the accuracy of our edits and reviews.
How do we accomplish rising adoption rates and plummeting dispute rates? There are a few important factors:
- Rock-solid sourcing: Our edits and reviews are based on industry-standard references and sources (CMS, AMA, AHA and others).
- Provider support: The team handles over 100,000 provider calls annually on behalf of clients, offering vital guidance and information right when needed.
- Prompt dispute resolution: Most disputes are resolved in less than 15 days.*
These factors and others lead to Zelis being trusted by our payer clients and providers alike.
The bottom line
Prepay accuracy is more than a technical upgrade — it’s a strategic shift that benefits payers, providers, and patients alike. By reducing friction, improving outcomes and fostering trust, it paves the way for a more efficient and collaborative healthcare system.
*Zelis proprietary data
