A large Managed Care Organization (MCO) was experiencing inappropriate payments related to non-covered benefits and for services with improper prior authorizations associated with paid claims. The organization approached AArete to develop a solution to ensure their configuration was appropriately capturing payments for current benefit requirements from the state and health plan.
AArete reviewed all relevant existing benefits and prior authorization policies, with the goal of estimating recoupment opportunities and prospective savings by aligning internal sources of configuration. We developed logic to identify payments for non-covered benefits, services reimbursed across multiple lines of business, and claims with improper prior authorization documentation. To support future benefits edits and configuration efforts, we constructed a comprehensive intuitive benefits matrix that could be updated with coverage changes.
AArete identified reimbursement for various non-covered services and services with incorrect prior authorization documentation, in addition to configuration edits that should have been implemented previously, but were withheld due to system and resource limitations. The identified recoupment and annual prospective savings accounted for a 9:1 return on investment and our tool allowed the configuration team to easily track state or plan issued benefits changes, resulting in process improvements and operational efficiencies.