Unsung Regence heroes have saved members nearly $700,000 so far in 2022
When using health insurance to visit a doctor, many members may not know how the doctor gets paid for their service.
Doctor offices create a claim – like a bill – for the patient’s health insurer after providing a service. Claims are basically requests for payment for those services. Some examples include:
- A telehealth appointment after catching a bad case of the flu
- A visit with a behavioral or mental health provider like a therapist or counselor
- When you fill a prescription at a pharmacy or through mail order
Regence reviews claims for accuracy and savings for health plan members
One way we help our members and their families save money is by reviewing claims for accuracy before we pay them. How many claims? So far this year, we have processed more than 34.6 million claims. Of those, 132,596 have been identified as needing a more thorough review. We use tools such as artificial intelligence and other technology to ensure provider payments and members’ out-of-pocket costs are accurate.
Regular audits are another way we protect our members’ financial health. This includes work done by Regence’s Claims Outlier Prepayment System (COPS) team. While members never see their work, the team’s daily focus on claims accuracy has a big impact. Since 2015, when it was formed, the COPS team has saved members $15.8 million in out-of-pocket costs.
The COPS system finds provider claims that are inaccurate based on the services received, the members’ benefits or provider reimbursement policies. Some of the most common errors include providers inadvertently overcharging for services or double billing, for example:
- A member goes to the emergency room (ER) with a headache and then is discharged. They return to the ER a day later with more severe symptoms and are admitted to the hospital. In this case, the member should only be billed for one copay or one coinsurance visit. Oftentimes, though, Regence will get two claims – one for the ER visit and one for the hospital visit. If these claims errors weren’t caught, the member would be billed for an ER copay and coinsurance as well as a hospital copay and coinsurance. So far this year, the team has saved members nearly $1 million through these catches. And it’s saved health plans – often funded by employers – more than $66,000 in unnecessary costs.
- ER upcoding is when a doctor bills for a higher level of service than what the patient’s condition warranted. If these errors went unchecked, the member would be stuck with a higher coinsurance than appropriate. Catching ER upcoding has saved members $693,000 so far this year.
- A simple example is duplicate claims, where the system catches two claims for the same person for the same service from the same provider. In one case, we saved the member nearly $2,000 in out-of-pocket costs.
In late 2019, the Journal of the American Medical Association estimated as many as a third of claims industry-wide are paid incorrectly each year, contributing to more than $760 billion in annual waste. The Regence COPS team is one way we are doing our part to reduce waste and protect our members from inaccurate billing practices.