Hospital claims are typically the largest and most challenging risk for health plans and payers. Although clinical outcomes may be favorable, inappropriate billing practices and errors, significant inflation of charge and non-covered services may not be identified, resulting in excessive claim payments. Negotiated contract terms should be applied to correctly billed charges and using discounts alone is not an effective strategy to mitigate risk. Ensuring claim payment integrity either prospectively or retrospectively is a necessity which can be challenging due to the complexity and high level of detail inherent in hospital claims.
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