First, let’s introduce you to Healthcare Fraud Shield’s new Director of Prepayment Review, Alexandria Denton. Alex’s work has spanned across industries in healthcare, hospitality, and holistic well-being. The trajectory of humanity and addressing social needs have been primary areas of focus throughout her life and work. Having worked in healthcare for the past 22 years has been as much about finding ways to give back as it is about moving forward with her personal and professional growth. In that work, it became apparent to Alex that healthcare fraud impacts our nation’s GDP significantly and the overall health of our nation’s healthcare system. The vast sums of dollars lost to healthcare fraud impacts people’s lives and the care people need. Alex has spent the last 13 years as a chief strategist and architect in designing solutions to end healthcare fraud & abuse as part of making a healthier healthcare system for all. Alex is truly inspired that she gets to work on solving these problems at Healthcare Fraud Shield now. As Alex has said, the people and their products are incredible.

The Value of Prepayment Software and Claims Reviews

Prepayment Claims Review is when claims billed by healthcare providers are pended by a payor’s claims processing system for claims review before payment is made but after the service has been provided. An important detail to note is that services provided to members are not disrupted. Payments made to providers are examined either through data analytics, clinical review – with or without medical records – to ensure what is billed is appropriate, actually occurred, and was necessary.

There are already plenty of audit types in healthcare. What is the value of prepayment claims review?

There are several key and important reasons prepayment review is a vital tool that payers want to include in a comprehensive program integrity system. Healthcare fraud happens in real time. A critical aspect of protecting healthcare programs and payers is protecting the dollars before they go out the door while also identifying schemes and potentially fraudulent activities as they occur. While the traditional retrospective investigative approach is still an integral and necessary function, stopping suspect claims before they are paid is vital in impacting the growing fraud, waste, and abuse (FWA) crisis. Further, investigators often want to know what occurred last week versus what occurred several years ago. Prepayment review also avoids costly, lengthy, and often unsuccessful payment recoupments with other types of audits.

Most importantly, prepayment efforts can help potentially save lives. According to Johns Hopkins (JAMA, 2019), “Patients treated by providers found to have committed fraud and abuse were more likely to die, require emergency hospitalization”.i

Healthcare Fraud Shield’s pre-payment detection system, PreShield is uniquely designed as an integrated component within the FWAShield platform and our Prepay Services. PreShield allows for real-time prepay rule detection and the ability to leverage analytics, trends and outputs using PostShield, the post-payment fraud detection module. PreShield is also integrated with CaseShield, the case tracking tool. This information allows a plan or government agency to take more decisive action and provides deeper insights into the scope and patterns of fraudulent schemes. The built-in workflow creates additional efficiencies, allows for greater tracking and reporting of results.

Fraud happens NOW. Inquire today to learn how you can proactively prevent fraud and abuse, save lives, and millions of dollars that can go towards enhancing your member services and program. If you have any questions or comments, please reach out to [email protected].