Enhancing our payment integrity program

We’re committed to ensuring the effective use and management of resources in care delivery to our members. To achieve this aim, we operate a Payment Integrity program. Our program focuses on billing / coding errors and overutilization of services or other practices that directly or indirectly result in unnecessary costs.

As part of this program, we administer audits with the help of our vendor partners, to make sure already processed claims were billed and handled properly. We’re constantly monitoring these audit programs, and from time to time, we make updates or implement new ones based on our claims data.

This summer, we’re enhancing our payment integrity program with a new audit for outpatient and professional claims across all lines of business. This new audit will look at several service types, including:

  • Outpatient diagnostic testing services
  • Outpatient surgery
  • Radiology
  • Independent lab and labs in outpatient hospitals
  • Pharmacy
  • Observation stays

As with all our payment integrity initiatives, this audit uses industry standard billing and processing criteria.

For more information about our payment integrity program, see our Payment Integrity page linked below.

Payment Integrity program