Third Party Administrator Claim Audit Report - wship

IV.RecommendationsImplement or revise policies and procedures in the following areas:In addition to the responsive suggestions made by BMI in each claims categoryabove, the recommendations below are offered for discussion between WSHIP and BMI.Some of these recommendations may ultimately be decided by WSHIP not to bewarranted, based on issues related to handling of transitional items from ACS to BMI. Inother words, some of these issues may have already been handled through the completionof the transition from ACS to BMI.• Require detailed itemized bills for out-of-network facility claims in excess of a prespecifiedamount (i.e. $10,000). Review the details bills for billing accuracy, medicalnecessity, appropriateness, non-covered items, etc.• Review out-of-network claims in excess of a pre-specified amount (i.e. $5,000) forpotential discounts.• Conduct pre-existing conditions investigations and maintain related documentation,train staff as necessary. .• Maintain pre-certification information received from Health Integrated with theclaims or online to ensure timely processing of claims requiring certification. Thepre-cert information should include the date on which authorization was requestedand authorized.• Duplicate checking – Continue to check for duplicates in ACS claim history for datesof service prior to the takeover.24