Ever pulled a loose thread from a sweater? Pull hard enough, and it might just begin to unravel, following threads and revealing a less than perfectly constructed garment.
If logic mapping is a sweater, pulling out a loose thread could mean detecting a small error in the system or unraveling system-wide issues.
Auditing adjudication logic is an important tool to keep your system running without error. But, performing an audit can be challenging and requires experience, time, and patience to unearth mistakes and correct them across a system.
When the logic fails on a claim’s system, it’s often up to the claims examiner to follow the thread and discover the more significant issue. However, tracing the error to its source can take time.
Suppose you don’t have a dedicated staff member to handle adjudication logic. In that case, you may pull the examiner from their day-to-day work into the deep end of a complicated system they may not be entirely comfortable with. And the truth is, finding one logic error is usually the start, not the end.
Failures in logic are relatively common and typically caused by one of two issues:
- Under mapping, or out-of-the-box software with basic or no mapping can risk missing out on benefit’s full payment.
- Over mapping, or taking a full range of codes, mapping them, and oversimplifying their payout.
Both mistakes mean you’re not taking full advantage of your payment plan in the way it was written, which could translate to incorrect payouts that cost you in the long run.
If your team is running into multiple failures in mapping logic, it may be time to run a full audit. Being able to trace mapping logic errors to their source can unravel long-forgotten errors in code, which increases auto adjudication rates.
The challenge is many teams aren’t equipped to puzzle through their mapping logic on their own. Whether it’s being strapped for time or experience, you don’t have to wade through this alone.
At JMS, we have an experienced team that’s passionate about making your logic work for you. We can work with you to untangle logic mapping with mastery in all systems, creating a more efficient system with better automation. That means less time manually processing claims.
Ready to start unraveling your logic mapping. Reach out to us today for a custom solution.
