Prospective Claims Accuracy

Stop Overpayments In Their Tracks

The best way to recover mispaid claims is to stop them before they happen. We were the first and only company to develop a post-adjudication, pre-payment identification, validation and correction solution that integrates seamlessly with your claims payment schedule.

The first step is using predictive, data-driven algorithms guided by your policies and contracts to identify mispayments. Then we go the extra mile with expert quality review and validation. Our highly experienced medical claims processors correct payment and financial accuracy errors before the payment is released, immediately improving your claims quality and reducing unwanted back-end identification and recovery costs.

Why this solution?

Increased Quality and Satisfaction

Paying claims correctly the first time enhances your provider and member experience.

Immediate Return

Mispayments never go out the door, instantly impacting your financial performance and claims accuracy.

Manual Validation

Increased automation doesn’t always equate to increased accuracy. We catch and correct the errors that your rules-based editing solutions can’t.

Wide Scope

Our comprehensive solution identifies a broad range of overpayment causes, such as coordination of benefits, contractual errors and duplicate payments.

  • PreVent
  • Data Mining
  • Analytics
  • Root Causes

PreVent

PreVent

Your first line of defense

Working seamlessly with your claims process and policies, PreVent augments your existing adjudication and prepay tools to stop mispayments in their tracks. How does it work? Adjudicated (but not yet paid) claims data is securely sent to Accent where proprietary algorithms and custom client  edits are immediately applied. Audit professionals quickly uncover hidden and complex potential overpayments that are carefully validated via view-only system access. After a final quality review, we correct the claim in your system or return a file with detailed findings for the claim to be paid correctly.

Our vast array of capabilities includes COB, duplicates, contractual liability, CMS compliance, exclusions, global services, billing errors, fee-schedule audits and more. This optimized process happens in less than 24 hours, which leads to more accurate payments and an immediate increase in medical and administrative savings. Unlike standard fee-for-service claim code editing software, PreVent’s contingency-fee pricing arrangement ensures we bear the risk while you receive the reward.

  • Improves provider and member experience by correctly paying claims the first time.
  • Reduces costly recovery and administrative expenses.
  • Manual validation by claims experts increases quality.
  • Helps you avoid total loss of dollars when providers won’t refund.
  • Decreases your medical loss ratio.
  • True cost avoidance of hundreds of millions of dollars.
  • Preserves your timely processing metrics.

Data Mining

Data Mining

The heart of our process

We help you improve the health of your payment integrity program with a comprehensive and flexible approach to claims data mining. Developed from decades of operational insights, our proprietary data-mining application leverages advanced technology and an understanding of payment challenges across the claims continuum.

Our dynamic system of programmable and customizable electronic edits is continuously supplemented with expertise from our research and development team, which constantly monitors the market, your policies, provider contracts, and changes in coding or billing rules and in federal or state regulations for new overpayment triggers.

A flexible search engine allows our experts to quickly and easily query, filter and interpret thousands of claims to discover overpayment anomalies in your data. We then automate our experts’ decision logic to create new concepts that drive expanded savings for our clients.

  • We identify a full range of improperly paid claims and focus on the areas that your team does not.
  • We’ll provide 100% manual validation to verify and calculate potential overpayments, thus ensuring quality and protecting your valuable provider relationships.
  • When an overpayment is discovered, we’ll review the claim history for previous instances of similar mispayment to optimize your return.

Analytics

Analytics

The brains of our system

We’ve built a Center for Data Science (CDS) that provides value to your team beyond mispayment identification and recovery. This group uses state-of-the-art data analytics to develop proprietary models of your claims portfolio to optimize the identification and recovery processes and to prevent future overpayments. The CDS allows us to customize our approach on your behalf, proactively improving your payment integrity and maximizing your return.

  • Predictive and prescriptive modeling for continual insight into your claims payment integrity program.
  • Data-driven decision-making and business optimization.
  • Comprehensive and actionable data analytics to strengthen incremental, value-added savings.

Root Causes

Root Causes

Eliminate future overpayments

Root-cause analysis integrates our data-mining outcomes, CDS analytics and payment-integrity expertise to provide you with insights about what is driving your claims mispayments. We’ll share our knowledge with you so you can enforce policies, fix systems or provide additional training to prevent future overpayments. We work with you on a continuous and dynamic process to change and improve your payment accuracy and reduce costs.

  • Coupled with our data mining and analytics, we help you resolve previously unidentified challenges.
  • Our process drives improved quality metrics and increased compliance.
  • Armed with analytics and new insights, we will help you execute the industry’s leading payment-integrity and cost-containment strategies.
  • We provide a transparent data ecosystem because it’s the right thing to do.