Ineffective claims editing leads to a cascade of expensive problems, including high error rates, inaccurate and inconsistent assessment of claims, penalties for regulatory noncompliance, unnecessary overhead, and fraud and litigation costs. In addition, the ability to attract and retain participating providers depends in large part on the payer’s ability to process and settle claims quickly and accurately.
The following are best practices for claims editing:
1. Use the rules in effect on the date of service.
2. Source edits at the code relationship level.
3. Provide full disclosure and transparency on web portals and explanations of benefits (EOBs).
4. Improve workflow efficiency by integrating rules engine capabilities.
5. Use the right rules for facility claims editing.
6. Customize rules to suit individual plans and lines of business.