10 Best Practices to Optimize Prepay Editing
Prepay claims editing isn’t just another operational task—it’s a powerful approach helping health plans stay ahead of the curve and streamline their entire workflow. As Mike Spellman, Senior Director of Consulting Services at Lyric, explains, following key best practices not only reduces costs but also builds trust and improves the overall experience for providers, members, and the plan itself.
It starts with staying current on industry regulations. Rules from Centers for Medicare & Medicaid Services, the American Medical Association, and others evolve constantly. Keeping up ensures compliance, protects the bottom line, and simplifies operations.
Next is strategic alignment. Claims editing shouldn’t be viewed solely as a cost-cutting measure; rather, it should help strengthen provider relationships. By balancing established rules with new data-driven strategies, health plans can foster collaboration and mutual benefit.
Artificial intelligence plays a crucial role in unlocking greater accuracy. AI identifies patterns and anomalies that humans might miss, providing insights for more precise decisions. Regularly revisiting carve-outs and filters is equally important—healthcare changes quickly, so these exclusions must be updated to remain effective and relevant. Diagnosis editing can be a goldmine for identifying missed opportunities: leveraging content libraries and health information specialists to drive greater accuracy in coding and reporting.
Efficiency in claims processing directly impacts financial performance. Streamlining workflows reduces administrative burdens, while preventing post-payment issues before they occur—through effective pre-service edits—spares unnecessary hassles. Transparency in adjudication is also vital. When providers understand how and why decisions are made, trust increases, leading to reduced provder abrasion and fewer appeals.
Aligning operations across the board ensures editing rules and tools work together seamlessly. Finally, remember the members: giving them clear, accurate information about payment policies helps build trust and confidence. This helps improve experiences and satisfaction levels.
By following these best practices—staying informed, using AI, refining strategies, fostering transparency, and focusing on both providers and members—health plans can unlock new value, reduce risk, and achieve lasting success. With Lyric’s decades of experience, you can tap into the full potential of prepay claims editing to reach these goals.
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