When it comes to the medical industry, there are plenty of roles and jobs that may spring to mind, such as surgeons and nurses. However, there is also an analytical, business side to the healthcare industry, in which a lot of data has to be collected and analyzed for a variety of reasons. Here are just a few of the tools, methods and software that are available for this purpose, and are widely used throughout the industry.

Health Plan Overpayment Recovery

It can be tricky to pick up on errors in a claims payment, as there may be a large volume of information or claims to get through, and small errors can be easily missed. These little errors will add up over time, causing losses for the organization, which will have a knock-on effect. When dealing with health insurance overpayment recovery, there are many areas in which errors can crop up including capitation, per diems, outpatient surgery and fee for service. For example, a claim may get billed twice by accident, or on purpose, and the repeated claim is not denied. In this case, the organization will lose money and if records are not properly kept or audited, the reasons for this may not be clear.

Keeping tabs on claims and overpayments helps to save money, and also to make sure people get paid the correct amount. A combination of software and in-person auditing can help to keep an eye on these areas, even being able to go back over data from previous years.

HEDIS Reporting

HEDIS stands for Healthcare Effectiveness Data and Information Set, and is a set of over 90 measures that fit into six different domains of care. These are:

Experience of care

Effectiveness of care

Access/availability of care

Utilization and risk adjusted utilization

Health plan descriptive information

Measures reported using electronic clinical data systems

Every year, the measures are revisited and evaluated, resulting in removal, additions and edits. The aim of HEDIS reporting is to collect data from different healthcare organizations, and use this to assess the performance of their different healthcare plans. This has benefits for the organizations, as they can see where they need to improve and where they are succeeding, as well as the patients, as the results may help to influence their choice of healthcare plan.

Audits

Audits happen in any industry or business, and are the external and objective analysis of part of a business. Usually, this is the financial element, and the aim of financial audits is to prevent and identify fraud, and make sure all financial books and paperwork are present and correct. Medical audits can be done to ensure that spending is correct, but also to evaluate other areas and records, for example during HEDIS data collection or while looking over paperwork and records in regard to claims and overpayments. 

There are many benefits to getting an audit done - not only does it show the public and investors that you have nothing to hide, it also provides you with recent data upon which you can make informed decisions about elements of the business or organization.