11/01/03 - Auditing Paid Claims

The Board of Trustees contracted with HealthCare Insight to audit outpatient claims processed by the Carpenters Health and Security Plan. HealthCare Insight will review each line item of every claim to look for possible billing errors and other billing irregularities. Their review process is based on nationwide and regional billing standards using Current Procedural Terminology (CPT) codes, Healthcare Common Procedures Coding System (HCPCS), American Medical Association (AMA) guidelines, and Centers for Medicare and Medicaid Services (CMS) guidelines. Their audit will identify duplicate payments, unbundled coding, and other billing errors prior to our releasing the claim. If appropriate, we will share the results of the audit with the provider and the provider will be asked to re-bill the services. This process should be invisible to the patient and strict privacy guidelines will be followed.■