Regence’s Payment Integrity team saves members money by ensuring claims are accurate

By Regence
October 20, 2022
medical claims

Regence is committed to making health care more affordable for our members by negotiating with doctors, hospital systems and drug makers to ensure they are charging a fair price for care and services.

One way we help our members and their families save money is by reviewing claims – the bills that providers send us for patient care – for accuracy before we pay them. Our Payment Integrity team leads this work and helps save millions of dollars each year.

Shelley Dean, the director of payment integrity at Regence, spoke on a recent Health Payer Intelligence webcast about our Payment Integrity program, which includes a multidisciplinary team of nurses and medical directors reviewing claims, data scientists and coders shepherding artificial intelligence and other tools, and the utilization of pharmacy technicians and health care informatics specialists where appropriate.

Reviewing claims incorporates both manual review, where team members review individual claims, and automated review, where we incorporate artificial intelligence programs to look at claims for accuracy.

“We need to be good stewards of our members’ money,” Dean said. “Therefore, we have (our) Payment Integrity (program), which is designed to pay claims right the first time by focusing on addressing waste and abuse…If we're not looking at claims payments for accuracy, we could be overpaying things that will end up costing the member more in their copays and out-of-pocket expenses.”

So far this year, Regence has processed more than 34.6 million claims. Of those, more than 132,000 have been identified as needing a more thorough review. 

One part of our Payment Integrity program, the Claims Outlier Prepayment System (COPS) team, has saved members $15.8 million in out-of-pocket costs since the team was formed in 2015.

Some of the most common billing errors include providers inadvertently overcharging for services or double billing. It’s important to work collaboratively with providers through the process and keep them apprised of any new payment integrity initiatives you have planned, Dean said in the webcast.

“Think about those pieces of work that you’re going to be implementing over the next year. What are those pain points that the providers could potentially be experiencing? …It's really collaborating hands-on, making sure that (providers) have the necessary information about what's changing, so that they can provide their feedback as well. (The providers) may have a different point of view, and that's always something we should be looking at. We want to make sure we're doing the right things. And at the end of the day, they want to make sure we're paying for the services appropriately.”