Why Claims Accuracy Testing, QA Is not proving Useful for Healthcare

Healthcare agencies require getting back to basics when it comes to establishing and implementing their claims accuracy testing and quality assurance programs.

Let’s confront it. Testing is not working.  That is the bitter truth about the healthcare organization and its track record on claims accuracy testing and quality assurance.

The difficult truth is that this problem is costly – with a cost tag of over $275 billion in the United States of America each year, in accordance to the Centers for Medicare and Medicaid Services – and with the latest ICD-10 medical coding and other industry alterations, waste and costly mistakes are potentially even harder.

To start to comprehend the underlying reasons of this multi-billion-dollar issue, we conducted meta-analysis of 78 QA and testing assessments conducted within the healthcare industry dating from the year 2009 through the year 2015.

These 78 distinctive assessments from both the payer and contributor sides covered each phase of life-cycle testing of commercial healthcare data and claims procedure applications and platforms, their changes and customizations, interfaces to other networks that are utilized along the monetary path connecting the healthcare contributors to insurance payers.

Testing issues that invest to or even enable this multi-billion-dollar quality assurance issues appear in every section of testing from functional via systems integration and onto pre-production testing of fixes/patches and updates, and involved the every kind of testing from “black box” to “glass box.”

The meta-analysis disclosed a 40% attempt waste in test activities, ranging from strategy to execution. This waste is attributed to”

1) Missing test coverage

3) Ambiguous and error-laden test scenarios, cases, and scripts

4) Duplication of test coverage and testing tasks

5) Test environment problems

6) Applying the incorrect approach to testing  

The 2014-2015 World Quality Report projected that by the year 2017, 29% of IT spends will be in the proposed testing.

Combine that with the very known 40% attempt waste during the time of testing, and it is possible to observe that approximately one-eighths of the entire healthcare IT spend will be lost on incomplete, insufficient, and error-prone testing/experiments.