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Use Case

MMIT’s ReimbursementCodes APIs Speed Claim Review and Reduce Overpayments

  • Automated medical drug claim validation
  • Identification of coding errors and improper payments
  • Expanded review of lower-value claims
  • Faster, more accurate claims processing

Key Results

87% Reduction
In Improper Payments Following Automated Claims Review
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Challenge

When claims were flagged for review, a team member would enter the drug’s NDC into a website, identify the correct HCPCS code, enter the date of service and all dosing information, and determine the correct charge based on the applicable pricing rate.

As manual reviews are expensive and time consuming, suspect claims underneath a price threshold of $300 were not reviewed at all. For the Blues plan, this meant an estimated $250K in overpayments each year, as determined by a recent claims audit.

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Solution

The plan asked MMIT to create application programming interfaces (APIs) that mirrored each step of a manual claim review. The ReimbursementCodes suite of APIs automatically receives data elements from a claim, double-checks NDC/HCPCS alignment, validates date of service, and confirms the billable amount based on the correct rate.

Compliant claims are noted and verified, requiring no further human intervention. Miscoded claims are flagged for a reviewer, who can then reconcile, pend or deny them. The APIs can also validate that providers have complied with the rules for mandatory generic substitutions, unit conversions, and drug wastage.

Outcome

With the implementation of MMIT’s ReimbursementCodes Medical Drug Edits APIs, the plan now has a scalable claims review process, which allows for review of all potentially inaccurate claims—even those for smaller amounts.

“Before, it was death by a thousand cuts. We knew we were making overpayments for a large percentage of claims, but we didn’t have the resources to screen for accuracy,” said the plan’s Claims Director. “Now, we are finally equipped to ensure payment accuracy.”

With the same number of claims adjustors on board, the Blues plan is now processing four times as many claims for review as it did before. Adjustors have time to focus on reviewing outlier claims, such as those with not otherwise classified (NOC) codes.

Best of all, the plan has substantially reduced improper payments. According to a new audit, overpayments have dropped by 87%, and appeals have been halved.

FAQ

How can healthcare payers improve medical drug claims review and reduce overpayments?

Healthcare payers can improve claims review accuracy by automating validation processes that identify coding errors, incorrect billing amounts, and reimbursement discrepancies. MMIT’s ReimbursementCodes Medical Drug Edits APIs help payers verify NDC and HCPCS code alignment, validate billing information, and flag potentially inaccurate claims, reducing manual workloads and helping prevent improper payments.

How did MMIT's ReimbursementCodes APIs help the health plan improve claims processing efficiency?

MMIT’s ReimbursementCodes Medical Drug Edits APIs enabled a regional Blues health plan to automate medical drug claim validation and expand reviews to lower-value claims previously excluded from manual processing. With the same number of claims adjusters, the plan increased its review capacity fourfold, reduced overpayments by 87%, and cut appeals in half.

What are the benefits of automating medical drug reimbursement and coding validation?

Automating medical drug reimbursement validation helps healthcare payers identify billing inaccuracies, improve payment integrity, and streamline claims processing. MMIT’s ReimbursementCodes APIs verify coding alignment, dates of service, billing rates, and reimbursement requirements, allowing claims teams to focus on complex exceptions while reducing administrative costs and the risk of improper payments.

Streamline Claim Review

MMIT’s API functionality allows clients to leverage our adaptable data to serve a variety of business needs. Find out how our ReimbursementCodes APIs can help your team!
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