Claims Management: Taking a determined stand against Insurance fraud. Fraud is a growing problem and fighting fraud has considerable cost and profit potential for insurers. Insurers are putting their best efforts to capture this potential.
Many insurers do have fraud management systems in place. Compared with the demands of professional fraud prevention and protection, however, the industry is largely still in its starting blocks, and it cannot match the sophistication of those it is fighting, some of whom are highly professional. It is international best practice to use dedicated fraud specialists with specific skills (such as former police detectives).
BPK is to assist Insurers in developing and implementing a robust and consistent fraud investigation and medical audit system to detect, prevent, deter any fraud losses under Insurance in different stages. BPK follow the standard and best professional practices, formats for data capture to help in meaningful reporting and analysis. BPK also submit reports on antifraud measures with results achieved there of.
| Services for State and Central Government Health Scheme | ||
|---|---|---|
| Medical Audit | Hospital Audit | Mortality Audit |
| Insured Verification | Desk Audit | Beneficiary Audit |
Medical auditing is a systematic assessment of performance within a healthcare organization. Almost any element of healthcare can be audited, but most audits look at components of payer reimbursement processes to evaluate compliance with payer guidelines and federal and state regulations. By identifying errors and devising remedial actions to eliminate them, the medical audit serves a vital role in a healthcare organization’s compliance plan.
BPK conducts internal or external reviews of coding accuracy, policies, and procedures to ensure an organization is running an efficient and liability-free operation. The BPK auditor possess knowledge of medical coding, medical terminology, clinical documentation, compliance, and regulatory guidelines. Additionally, the auditor will determine the scope of an audit, use approved tools to perform the audit, compile the data, report the findings, and provide corrective recommendations. BPK medical auditors are experienced medical coders with advanced training.
A Medical Audit is a systematic review of an episode of medical care. This involves a step-by-step analysis of the medical procedure performed by a provider against the explicit criteria of necessity, quality of care and cost. It also includes verification of associated clinical notes, diagnostics, and documentation to validate if:
During hospitalization stage, fraud triggered cases, or the cases flagged by Preauth Processing Doctor are sent for medical audit. Audit team visits the hospital and conduct the audit based on the trigger and collect all required evidence. If fraud is confirmed before the discharge, then case is sent for action/denial of pre-authorization and if confirmed as non-fraud, the case is processed on merits as in normal course.
At the time of claim adjudication/ payment of the claim, the fraud triggers highlight certain cases as “suspect” these would need medical audit. Desk medical audit in these cases would be done for prima- facie/ fact verification to ensure that any apparent false positives are filtered out. If the case remains suspect post first level scrutiny, then the case will be sent for field investigation or field medical audit depending on the nature of fraud trigger and the evidence needed for verification.
During this process, the medical auditor conducts an audit from her/his desk, without visiting the hospital. S/he verifies case-related documents (prescription, clinical notes, investigation reports, discharges summary, etc.) presented by the hospital at the time of pre-auth request or claim submission. The purpose is to ascertain the necessity of treatment, qualifications of treating doctor and authenticity of claim as evidenced by the documents.
During this process the medical auditor visits the hospital premises to conduct live audits on flagged cases, reviews indoor case papers, clinical/operative notes etc. of suspect claims. During the process, the auditor also reviews associated hospital infrastructure and availability of required specialists/ resource, meets the treating doctor to establish if the procedure was performed in the facility ensuring appropriate quality of care. At the time of audit, if the beneficiaries are admitted in the hospital, then the auditor conducts live audits to establish the correctness of information recorded in the documents, necessity of treatment and obtain any feedback of the patient regarding the quality of service, and whether all benefits of the scheme were made available to her/him.
Patient is under treatment or has already been discharged and as need be, the medical auditor may visit hospital or beneficiary’s home to revalidate/corroborate the information/case papers etc. collected from the hospital and the procedure blocked/claim submitted.
Every death occurring in the Empanelled Hospital should have a mortality report prepared by the hospital. Each Hospital should submit a mortality report to the client at the time of claims submission within 7 days. Mortality and Morbidity Committee to conduct desk/ field mortality audit of all mortality cases.
BPK work with a range of industries and businesses of varying sizes across the business horizon. That enables us to handle more complex projects and deliver sustainable analytical solutions to our clients.
Analytics services help to measure the business's existing and real-time operations. BPK professionals help process data that converts into insights that help the client to make the necessary changes in existing operational workflows and procedures to align it with the results that match your consumers’ expectations.
BPK follow an organized data analytics process that involves everything from understanding client’s requirement in providing insights that help to resolve client’s business concerns and make the necessary improvements to achieve the objectives.
BPK performance analytical support helps you leverage data relating to the performance of every unit across the organization. The insights prove a guideline to bring the necessary improvements in departmental and organizational performance, thereby also increasing customer satisfaction levels.
Ideally, all projects and programs should have monitoring systems that gather information about beneficiaries and their perceptions, views and responses to the interventions. Such information can be gathered for both individual and institutional beneficiaries through a wide variety of data collection methods. Even when the information is not comprehensive, it will undoubtedly help in improving the performance and impacts of their projects and programs.
BPK conducts beneficiary feedback in four stages of evaluation, namely planning & designing, data collection, formulation of findings, conclusions & recommendations and finally dissemination of evaluation reports.
BPK provides Operations support services to TPA's in Preauthorization, Claims, Enrollment and Field Activities on outsourcing basis to meet their TATs as per the huge volume and demand from their stake holders.
BPK team of expert consultants work side-by-side with your team to define and execute an implementation plan based on your requirements.
We BPK Global Solutions Pvt Ltd are the specialized first of its kind company that offers one stop shop dedicated services, solutions and consulting on all advanced technologies in Insurance & Assurance Claims Investigation and Allied Services.
Copyright © 2023 BPK GLOBAL SOLUTIONS PRIVATE LIMITED - All Rights Reserved.
