Balancing the financial fitness of a health plan with effective delivery of healthcare requires that plan providers navigate a complex process of financial analysis, auditing and, when necessary, overpayment recovery.

In today’s high volume healthcare environment, plans rely primarily on computerized adjudication systems configured to pay claims as specified in the physician group/plan provider contract.

This process of automated adjudication allows efficient management of payment based on claims coded through current coding standards, predominantly CPT or HCPCS. The adjudication process applies the rules of the contract to the incoming coded claim which then determines the proper payment on that claim.

With a properly coded claim, processed through a properly configured adjudication system, health plan providers can effectively manage the many thousands of incoming claims from its physician group, thus ensuring the smooth delivery of health care services to a member population.

But what happens when there is an error somewhere in this process chain? How do overpayments happen, and what are the remedies when they do?

Accurate claims adjudication: set it and forget it, but don’t really.

Configuration is the name for the process by which the multi-million dollar software programs that process claims automatically are programmed to pay according to the terms of physician and hospital contracts.  When an adjudication system is misconfigured, sometimes hundreds of claims representing thousands of dollars are processed inco