In claims progressing, algorithms – mathematical formulas used to scrutinize particular elements of a claim form – can be good when used to ensure the accuracy and consistency of claim payments… but bad when used as a tool to deny claims.

In a class action lawsuit, a national health insurer has been accused of using an algorithm to improperly reject claims in bulk. The suit asserts that the insurer used software to “deny payment in batches of hundreds or thousands at a time,” at a rate that makes it impossible for the claims to be reviewed individually. The insurer refutes the allegation.

MedBen uses algorithms for a different purpose: To pay the right claim at the right price. A proprietary surveillance system draws on thousands of physician-developed algorithms to find claims with loss potential. Board-certified specialists then evaluate those claims and work with providers to correct disparities. On average, this forensic claims review saves 49.2% per selected claim, over and above any PPO discounts.

We’ll note here that the rejected claims cited in the suit were for fully-insured plans, not self-funded… but that also highlights an important distinction between the two types of coverage. With self-funding, there’s no incentive to auto-deny claims. Rather, the goal is to ensure that every claim is paid commensurate to the care received and in accordance with the plan’s pricing model. This approach benefits employer, plan member and provide alike.

If you have any questions about how MedBen pays your claims, just call us at 888-627-8683.