How Shifting the Focus from Claim to Member Is Improving Payment Accuracy

December 5, 2019 Gary Call

A medical claim can tell us a lot about a patient’s encounter with the healthcare system — from diagnosis and treatment to the services and procedures billed. When examined holistically, claims data can also reveal valuable insight into a patient’s journey through the continuum of care.

As we work to tailor healthcare services to the diverse and multifaceted needs of each patient, applying a similarly holistic approach to the claims review process will allow us to better identify systemic inefficiencies and address them in a manner that benefits all healthcare stakeholders.

Episodes of Care: Uncovering the Big Healthcare Picture
Episode-based models have emerged as a way to improve health outcomes while reducing the total cost of care. Broadly defined as consisting of “all clinically-related services for one patient for a discrete diagnostic condition from the onset of symptoms until treatment is complete ,” episodes of care seek to improve the quality and efficiency of care through an incentive-driven approach. By bundling health services — and payment for those services — around a particular episode, such as a heart attack or acute kidney failure, providers are encouraged to maximize their efforts to deliver lower volume, higher value care.

While episodes of care present significant potential in streamlining care management, as with any performance or value-based model, integration is key. The coordination of people, systems and data through all stages of the patient journey and across various care settings is equal parts necessity and challenge — vital to patient-centric care but evermore difficult as healthcare needs become increasingly complex.

In many ways, grouping health services and resource use into episodes is helping to bridge gaps in care by rewarding productivity gained through cross-functional collaboration. However, discrepancies between facility and physician coding can render these efforts at least partially ineffective, leading to overbilling and payment inaccuracies that exacerbate healthcare waste and negatively impact the payer’s bottom line.

A Member-Centric Approach to Healthcare Payment Accuracy
As an industry, we must work together to achieve the triple aim of improving care, health and cost — a goal that rests on a pervasive commitment to innovation and collaborative ideology. Concentrating these efforts around population health and payment accuracy, HMS has developed several purpose-built solutions to optimize the revenue cycle for all parties, with a specialized focus on health plan program integrity.

Episode of Care is HMS’ most cutting-edge payment accuracy solution yet. Leveraging claims data alone, Episode of Care follows the patient journey through a particular condition or procedure, identifying discrepancies in coding and billing based on the full care experience — prior to, alongside and after the claim in question. Machine learning analytics are used to identify suspect claims, which are then escalated to a clinical recovery specialist for further review. Using HMS’ advanced clinical review platform, the claim is assessed against the patient’s history to determine which of the conflicting diagnoses or procedures billed is correct.

In the case of overpayment, HMS promptly pursues recovery on behalf of the payer. By letting the claims tell the story, Episode of Care eliminates the need to request medical records, significantly accelerating the recovery process for the payer without adding to the already heavy administrative burden placed on the provider.

Episode of Care is just one example of how continuous innovation is enhancing efficiencies for payers, providers and patients, while advancing the universal goal of creating a better healthcare system overall.


[1] Bottle, A., & Aylin, P. (2017). Statistical Methods for Healthcare Performance Monitoring. Retrieved from

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