Role of Proto-Link API in Payment Integrity In the ever-evolving landscape of healthcare finance, payment integrity has become a foundation of payer strategy, particularly as we navigate the complexities of 2023's regulatory environment. With the costs associated with payment inaccuracies climbing, health payers are actively seeking innovative solutions to bolster their systems against the dual challenges of waste and fraud. As a critical component of this effort, technologies like Proto-Link API and UR Express are stepping into the spotlight, offering a blend of automation and precision that promises to change healthcare payment processes. This article delves into the strategic application of these technologies.
The impact of automation in healthcare:
The healthcare industry faces substantial financial losses due to administrative complexities and fraudulent activities, estimated between $58.5 to $83.9 billion per year. To combat this, a push for increased automation and customized claims adjudication processes is crucial. In a trial of the utilization review process for workers’ compensation, the ProtoLytic UR Express program increase productivity of UR nurses by over 20% when compared to the largest competitor from DataCare called UR++. One study of a large insurance carrier showed that using the Proto-Link API to automate the initial review of claims would result in a $9 million savings per year in labor by automatically authorizing procedures without costly manual review.
Medicare Advantage payment challenges:
A 2019 review highlighted that 18% of Medicare Advantage (MA) plan payment denials were incorrect and denied claims that fully complied with Medicare coverage and billing rules. The U.S. Office of Inspector General identified manual reviews by Medicare Advantage staff were prone to human error and are the root cause of these erroneous denials. Integrating the Proto-Link API into a prospective review strategy will mitigate these errors and streamline the claims process. Transitioning from reactive post-invoice reviews to proactive pre-pay evaluations can lead to more efficient workflows and reduce unnecessary delays in payments.
Expanded role of the US Department of Labor:
The U.S. Department of Labor is taking on a larger role in ensuring payment integrity and provides detailed procedures for reviewing medical evidence as part of the claims process under the Office of Workers' Compensation Programs (OWCP). The DOL sets guidelines to ensure that claims are not only accurate but also justifiably related to workplace injuries covered under federal compensation laws.
- Medical evidence reviews:
- The DOL requires a thorough cross-checking of the diagnosis on the bill with the condition accepted by OWCP. It requires consistency across medical reports and November 8, 2023 billing forms, ensuring that the treatments are reasonably related to the diagnosed conditions.
- Detailed scrutiny is advised for the treatment dates and the reasonableness of the period of treatment provided, aligning with the accepted conditions.
- Attention is directed towards identifying any pre-existing conditions that might have been treated simultaneously, ensuring that the billing is strictly related to the work injury.
- Prescription drug assessment:
- Physicians are expected to list all prescribed drugs in their reports, and bills for prescription drugs should detail the drugs, amounts, and prescribing physician. The DOL suggests consulting the Physicians’ Desk Reference to validate the appropriateness of the prescription for the condition accepted.
These standards are designed to reduce improper payments, which could be due to fraud, abuse, or administrative error.
The Proto-Link API will significantly streamline compliance with these DOL guidelines. By integrating with medical billing systems, the API can automatically:
- Cross-reference diagnoses and treatments with the conditions accepted by OWCP.
- Confirm that prescription drugs billed are indeed listed in the physician’s report and are appropriate for the accepted condition.
The API’s ability to automate these checks not only aligns with the DOL’s protocols but also enhances efficiency, reduces the administrative burden, and lowers the risk of payment errors. This alignment with federal standards ensures that payers can maintain high levels of payment integrity while also being prepared for potential audits or compliance reviews.
Conclusion:
The need to strengthen payment integrity in healthcare is clear as we move into 2023. The integration of disruptive solutions like Proto-Link API presents an opportunity to transcend traditional barriers to efficiency and accuracy in claims processing. The costs and inaccuracy of manual reviews, the need for enhanced automation, and the guidelines set by the U.S. Department of Labor dictate a new framework is needed for payment integrity.
Proto-Link API emerges as a key tool in this landscape, offering the potential to streamline processes, minimize human error, and uphold the rigorous standards required for healthcare payments. By automating and customizing claims adjudication, Proto-Link API not only aligns with industry best practices but also supports the prevention of unnecessary financial losses due to inefficiencies and inaccuracies.
Healthcare payers who integrate the UR Express platform and the Proto-Link API can look forward to a future where payment integrity is a reality, ensuring that dollars spent contribute to the provision of high-quality healthcare. As the industry evolves, so too must our approaches to payment integrity, with innovative technologies leading the charge in creating a more reliable, transparent, and effective healthcare payment system.