BlueCross BlueShield: CAS 5.0 Auditing Solution

BlueCross BlueShield of Western New York (BCBSWNY) and BlueShield of Northeastern New York (BSNENY) are divisions of one of New York’s leading health insurance and employee benefit solution companies, providing quality health plans and innovative benefit solutions for more than 836,000 members across New York.  The insurer’s Special Investigative Unit needed to increase internal visibilty and support business units in achieving corporate business objectives and to align anti-fraud and audit programs with company revenue goals.

The Challenge
The Reimbursement Integrity Unit needed a claims tool to identify improperly paid claims and to identify overpayments for recovery. The Special Investigation Unit needed a fraud detection tool to identify potentially fraudulent claims. In addition, the client needed to ensure clear, consistent communication; prevent duplication of efforts/reported recovery; standardize the reporting of cost recoveries; develop recovery reports specific to each business unit; customize edits for “carved out” services for certain lines of business; and ensure quicker resolution of issues. CGI’s Customized Audit System (CAS) software proved to be the ideal enterprise-wide claims audit solution for BCBSWNY/BSNENY.

How CGI Helped
CGI implemented CAS 5.0, a browser-based claims audit tool, to audit inpatient, outpatient and professional healthcare claims; identify fraudulent claims and track results; and expand to an enterprise type solution to eliminate duplication of efforts and customize audits by unit.

The Results
By implementing CGI’s CAS 5.0 technology, BCBSWNY/BSNENY has recovered more than $44 million during a five-year period. In addition, the client derives several other business benefits, including:

• Eliminated duplication of audit efforts
• Documented audit details at the claim level
• Automated the provider notification process
• Streamlined the claim adjustment process
• Automated recovery reporting process
• Increased recovery dollars

The bottom line: CAS 5.0 has helped BCBSWNY/BSNENY establish a new level of audit claims integrity and save money through more efficient dollar recoveries.

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