While the medical field itself requires great precision due to its complexity, it’s also essential to ensure the accuracy and timeliness of medical record completion. These documents contain codes that are used by insurance companies to create claims, determine reimbursement rates, and ultimately help determine coverage for a range of patient services.

Audit Process Shifts Away From Provider Network

In the past, insurance audits that check for duplicate codes, incorrect billing information, or other errors have centered around individual claims. However, this process can take up to a year due to the lengthy wait times for requested medical records. In order to expedite the process, health insurers have shifted the focus of these reviews to their members as a whole rather than specific provider claims. 

Insurance companies have found one of the best ways to do this is through episode of care reviews, which determine a member’s overall utilization by connecting each service to a diagnosis or medical procedure. This allows insurers to gain a large-scale view of a member’s care record to identify any gaps or errors that must be remedied. 

Beyond the insurance industry, these reviews cut down on fragmentation by getting members connected with services that pick up where others left off. The way in which episode of care reviews group services together helps improve efficiency and better integrate care for all.

This process helps insurance companies stay organized and efficient, but it also allows them to more quickly return overpayments to members, which helps increase overall satisfaction. Episode of care reviews help your provider network offer holistic care with better outcomes due to less fragmentation. Since this form of records review requires clinicians to have far less contact with insurance companies, it also improves productivity within the provider network.

Episode of care reviews are objectively a great option for insurance companies to improve the way they find and correct errors. These record reviews not only make the behind-the-scenes work more efficient, but they enhance the quality of care offered by provider networks. 

Another great way to level up the care your members receive is by building a formidable provider network. TOG Network Solutions can help you do just that to strengthen your business in these difficult times.