Payment Integrity | Denver Health Medical Plan

The Role of Payment Integrity in Health Care

The Payment integrity Department is responsible for ensuring that a claim for service is paid correctly. We verify that that the claim is properly coded, and the claim is in compliance with the diagnosis and various statutory and regulatory requirements. The Payment Integrity Department also provides oversight of the Special Investigation Unit (SIU).

In addition, the Payment Integrity team manages the subrogation process. Subrogation is a legal term that describes a right held by most insurance companies to legally pursue a third party that caused an insurance loss to the insured. When an insurer compensates its insured for a covered claim, subrogation authorizes an insurance company to seek reimbursement from the liable party. Some examples of subrogation claims are car accidents, slip and falls, medical malpractice, etc.

The Special Investigation Unit (SIU) overview:

The SIU is responsible for the following:

Establishing a case file for each referral as warranted
Obtaining necessary supporting documents for all case files, including copies of claims, contracts, correspondence, and other relevant documentation
Conducting a case investigation to conclusion in accordance with the procedures established by the SIU
Detection, prevention and investigation of Fraud, Waste and Abuse (FWA)

The SIU conducts inquiries, audits, investigations, and other related activities, which may involve:

Data collection
Conducting interviews
Performing data analysis
Coordination with the Division of Insurance and other federal and state agencies, as necessary

What actions the SIU is responsible for:

Contacts providers for recoupment of errant payments as appropriate
Educates providers as necessary
Implements Prospective Controls
Refers suspected fraud to the proper authorities
Implements Corrective Action Plans (CAPs)

The Payment Integrity Department consists of the following team members:

Payment Integrity Manager
Payment Integrity Investigator
Payment Integrity Investigator