Question: For our experiential learning application, you will use your knowledge of sampling to run the following scenario. A research study reviewed the differences between two
For our experiential learning application, you will use your knowledge of sampling to run the following scenario. A research study reviewed the differences between two methods for verifying selffunded medical claims. The two methods reviewed were verifying of claim exceptions or errors that were identified from all claims and a random sampling of claims. The claims data was collected from two Fortune corporations. The researchers found that the second random sample method missed many of the claim errors that were identified through the of claims review with the first method. Some of the missed errors contained $ $ in claim dollar values. To catch all the claim errors is an important goal for selffunded plans for ensuring lower expenditures. The process goal can follow a Six Sigma methodology, which is a quality improvement process, that ultimately seeks to obtain defects or errors. The researchers applied a fivestep protocol for the claims review. The steps are: All paid claims were loaded into a data warehouse. Eligibility data and benefits such as covered services, copays, administrative agreements, and rules are reviewed. Industry standards from Centers for Medicare and Medicaid Services CMS and others are used to detect exceptions. The data is compared against best practices and administrative processes. An onsite review is conducted for any claims identified for validation Sillup and Klimberg,
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