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Quality Assurance

Reduce errors and optimize your claims operations by better adhering to compliance regulations for healthcare.

Are incorrect claims impacting your bottom line?

Claims processing is one facet of the healthcare payer business that is prone to avoidable errors. Manual processing is one of the leading causes of making mistakes. By automating processes, healthcare payers can significantly reduce duplicate charges and other billing mistakes made that often go unnoticed.

Typically, discounts available through PPO Network often get missed or miscalculated, leading to massive overpayments. Coordination of Benefits (COB) and other third-party liability opportunities, such as subrogation, can also go undetected. All these over-payments are costs that have the power to significantly impact your bottom line.

MDI NetworX’s Quality Assurance service addresses these issues of overpayments and also checks for adherence to applicable compliance standards.

By regularly conducting process review, approval, audits, and systematic maintenance of quality systems, your organization can ensure compliance with applicable healthcare claims standards and regulations. The scope of review covers production and process controls, change management, validations, system testing, risk management, procedural review and creation, and process improvements.

How We Make It Work

At MDI NetworX, we have years of experience and extensive domain knowledge in auditing medical claims. This has placed us in the unique position of being at the forefront of addressing billing errors and payment integrity for healthcare payers. We are committed to your operations and therefore we employ rigorous validation, extensive quality checks, robust industry research, and ongoing education in order to continually deliver tangible results to our clients. Through our efforts, we have been able to successfully recover millions of dollars in overpayments for our clients, as well as ensure long-term process health by detecting and correcting root-cause issues.

Through our four-pronged approach, we:
  • Verify if systems and processes are in place
  • Validate coverage of dependents
  • Monitor claims payment accuracy
  • Identify and recover overpaid claims

We start by assessing existing claims and eligibility data using advanced electronic testing techniques. This covers claims adjustments and reversals with special attention given to determining payment accuracy.

Then we closely examine error logs prepared by the auditors. Our experienced staff searches for possible overpayments and, if required, reviews and re-calculates claims for quantifying financial impact. The final audit report provides recommendations to address identified process gaps in the audit.

We deploy advanced statistical techniques throughout our claims quality assurance process, such as custom data mapping, pattern detection, and regression analysis, to identify situations typically challenging to identify at the transactional level. Doing this provides significant recovery and prevention opportunities.

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