In 2014, the Office of Inspector General (OIG) reported that in its review of CMS payments for E/M services, 21% of all E/M claims were incorrectly coded and/or lacked documentation, resulting in $6.7 billion in inappropriate payments. Further, a recent analysis by Change Healthcare identified over 80,000 providers who are billing high-level E&M codes at a significantly higher frequency than their peers. While some might associate these with fraudulent billing practices, the truth is that most are driven by simple billing errors and gaps in the understanding of coding/reimbursement guidelines.
This presentation will describe how a payer organization developed an innovative approach by leveraging data analytics and collaborating with providers to mitigate billing aberrancies that has resulted in valuable medical cost savings. What makes this approach unique, compared to traditional strategies, is the ability to share data insights through prospective and consultative provider engagement.
How a collaborative approach to working with providers can result in a dramatic reduction in overbillings which drives down medical cost. Further the program – the only one of its kind in the industry – involves minimal risk and is delivered in a way that protects important provider relationships.
VP, Financial Investigations & Provider Review (FIPR),
Highmark Health BCBS
Kurt Spear is a Vice President at Highmark and has spent the last 4 years leading the Financial Investigations and Provider Review department. In his role, Kurt has a broad set of accountabilities that includes developing and overseeing member and provider fraud, waste and abuse investigations as well as savings and recovery strategies across all Highmark markets. Additionally, he partners with state, federal and local law enforcement agencies on instances of fraud and collaborates with external audit vendors to identify and recover healthcare overpayments.
Kurt has a Bachelors of Arts in Management and History as well as several industry certifications, including: Certified Fraud Examiner (CFE); Certified Information Systems Security Professional (CISSP); Certified Information Systems Auditor (CISA) and Certified in Risk and Information Systems Control (CRISC)
Director of Operations, Payment Integrity
Chris Hall has been with Change Healthcare for 19 years and is currently the Director of Operations for Payment Integrity. In addition to serving as a subject matter expert in Change Healthcare’s product and business development efforts, Chris’ current role has him leading the operations for the Coding Advisor solution. Having worked in the payment integrity space for over 21 years, Chris has extensive experience working as a thought leader in Fraud, Waste, and Abuse. Previous roles have allowed Chris to gain valuable industry exposure in the property/casualty arena, workers compensation, disability, life, and health. Chris is a Health Care Anti-Fraud Associate, has previously served a number of years as the co-chairman for the Midwest Anti-fraud Insurance Association, and has been a frequent guest speaker at numerous regional and national health care conferences.