E. Claims Performance Monitoring

Audit Program

Objective 1: A robust program for identifying and quantifying errors made in the claims adjudication process has been developed, documented, and implemented.

Audit Steps:

1. Determine whether the claims performance monitoring program includes a methodology that ensures consistent results, contains sufficient detail, targets, measures, and accountability for periodic reviews of the financial and payment incidence accuracy of claims processing. Obtain a copy of the claims performance monitoring program and related documentation, review of a sample of results and supporting schedules, interviews, and observations ensure the following:

A. The program has been documented in writing, has been approved by the appropriate level of management, reflects the current operating environment, and is available to all staff. B. The types and frequencies of each audit are documented in detail. C. Targets for financial and payment incidence accuracy are documented and defined. D. Sample sizes for each audit are defined. The sampling methodology is described. E. The audit process considers the end to end claim process (e.g. membership validation, benefits, COB, referral, authorization, pricing, etc.). F. Establishes the methodology for assigning errors to claims examiners and other departments. G. Documents the error notification and dispute process. H. Requires the use of source documents or systems are used to complete the review process.

2. Verify that the individuals performing claims performance monitoring reviews have received the training necessary to properly complete and document the various audits. Assess the training program by reviewing the training materials, and interview with a sample of staff. Objective 2: Samples selected for the claims quality assurance review accurately represent the population of claims transactions processed by the Claims department.

Audit Steps:

1. Determine whether the sampling methodology used to complete the claims quality assurance review results in a statistically valid sample, and is consistent with existing policies and procedures.

2. Validate that the sampling methodology ensures that all claims processed are included in the population subject to sampling.

Select a sample of months during the scope period (maximum of three) and determine whether the file used to select claims for review reconciled to the control total from the claims system (or general ledger) for the period being reviewed. Objective 3: The claims quality assurance process provides reasonable assurance that claims are paid accurately and timely.

Audit Steps:

1. Determine if the quality assurance auditor has properly identified whether claims have been processed accurately based on the member’s eligibility status for the date of service. Select a sample of audited claims and perform the following:

 Re-perform the test by determining whether the claims were processed accurately based on the member’s eligibility in the membership system.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

2. Ensure that the quality assurance auditor has assessed whether claims payments are coordinated correctly for members where the organization is the secondary insurer. Select a sample of audited claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on the member’s multiple coverages in the common membership system or on the claim form.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

3. Validate that the quality assurance auditor has properly identified if a member’s benefits (e.g. copays, coinsurance, and benefit accumulators) are applied to claims accurately per the membership system. Select a sample of audited claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on the member’s benefit coverage in the membership system.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented. 4. Verify that edits applied by the medical/clinical review systems are properly applied to the claim, and as appropriate that claims are routed and reviewed by the medical/clinical review per policy. Select a sample of claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on guidance from the software application or other established triggers.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

5. Ensure that the quality assurance auditors are properly evaluating the authorization process. Select a sample of claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on the authorization information listed in the claims system authorization table.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

6. Determine that the quality assurance auditor has properly identified whether claims are processed accurately based on contract information from the provider contracting application, original contract, or non- contracted provider policies. Select a sample of claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on the provider contract or non- contracted provider rates.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented. 7. Validate that the quality assurance auditors properly performed a review of the claims history to ensure duplicate claims payments were not made and that claims holds were released appropriately. Select a sample of claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on claim history indicating any duplicates or claims holds.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

8. Verify that the quality assurance auditor’s review of clerical accuracy is properly performed. Select a sample of claims bills and perform the following:

 Complete a re-performance test by determining whether the claim was processed accurately based on the clerical fields identified in the existing quality assurance audit program.  Verify that the audit re-performance results agree with the quality assurance auditor’s assessment. Any errors identified are documented.

9. Validate that management is properly reviewing quality assurance documentation to verify that payment errors were communicated and resolved timely. Select a sample of errors identified during the scope period and perform the following for each error identified:

 Validate via inquiry that management has an adequate process in place to address errors.  Determine if the error was included in the monthly review discussion attended by claims management, claims quality assurance, and other related areas. Any errors identified are documented.

10. Ensure that quality assurance auditors have read only access to the claims system. Objective 4: Quality assurance review results are communicated to management in a timely manner.

Audit Steps:

1. Verify that quality assurance audit results are shared with leadership in a timely and consistent manner. Select a sample of completed quality assurance audits completed during the scope period and complete the following:

 Any errors identified have been reviewed with the applicable claims examiner and their supervisor. The review is documented.  The audit was completed appropriately and in compliance with existing policies and procedures.  Corrective action was taken as necessary including disciplinary action if indicated.