Department of Public Welfare's Claims Audit Strategy
The Commonwealth of Pennsylvania’s Medical Program known as Medical Assistance (MA) Program enrolls healthcare providers who render services to eligible individuals. The Office of Medical Assistance Programs (OMAP) within the Department of Public Welfare (DPW) has administrative responsibility for the MA Program. In addition, the Bureau of Program Integrity (BPI) within the DPW is responsible for addressing non-compliance issues in the MA program.
The Challenge
OMAP wanted assistance to augment the work of the BPI, and both parties needed outside assistance to develop a comprehensive audit strategy for inpatient services for the next three years and beyond. In short, the client wanted to engage a company to provide service for auditing hospital-based services including inpatient, outpatient and professional claims to determine if they were reimbursed properly according to MA regulations. CGI’s experienced and credentialed clinical auditing team proved to be exactly what the DPW needed.
How CGI Helped
CGI implemented its own claims auditing software, CAS 5.0, to identify and track improperly paid claims. In addition, CGI’s CAS 5.0 software includes edit logic for claims selection and analysis capabilities; audit status tracking; coding guidelines and resources; communication module for letter generation; report generation; and maintenance of current ICD9-CM codes and DRG Grouper Versions, which helped to further facilitate the DPW’s selection and review of claims.
The Results
Over the past three years, CGI has helped the client identify more than $40 million in recoveries for recoupment. Additional benefits include:
- Automation of the process of offset adjustment of provider overpayments through an interface of CAS 5.0 and the DPW’s MMIS vendor.
- Enhanced provider relations and minimized provider burden through a CGI operated and managed Provider Call Center.
- Monthly administrative reports that provide the DPW with documented results of the audit process.
The bottom line: By working with CGI’s qualified and certified medical and audit personnel, the DPW’s Bureau of Program Integrity is able to effectively audit its claims, analyze payments and recover identified overpayments.
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