Q&A: Understanding commercial payers' claim review processes

Q: Are commercial payers allowed to conduct a pre- and post-payment review of the same claim?

A: Depending upon your contract, the payer might have the right to do a pre-payment and a post-payment audit of the same claim. Because payer contracting staff have traditionally been focused on getting the best rates for the top procedures and ensuring the negotiated rates are adhered to, other aspects of payer contracts might not be scrutinized, says Dawn Crump, MA, SSBB, CHC, senior director of revenue cycle solutions with MRO in Norristown, Pennsylvania.. Often, things such as audits and claim reviews, medical record requests, and appeal processes and timelines are unchanged from the payer’s basic contract language.

Payer contracts typically have a long lifespan—some can last for up to five years or more—so changing contract language might be a long-term goal, Crump says. In the meantime, track audits by payer, including by type, whether audits are pre- or post-payment, dollar value, service line, and volume. That data will help you determine what changes should be made and why.

For more information, see "Closing the loop on payer audit strategies" in the July 2020 issue of HIM Briefings.