Retrospective Claims Accuracy

30 Years of Cost-Containment Experience

For more than three decades, the industry’s leading payers have partnered with us for retrospective claims-accuracy solutions. The dynamic nature of healthcare, complex reimbursement contracts and changing regulations are making claims-payment accuracy and quality more challenging than ever before. When overpayments happen, you need to identify them quickly.

Using predictive, data-driven algorithms guided by your policies and contracts to identify mispayments is the first step. Our professionals — with extensive experience in claims processing, coding and auditing — promptly uncover hidden and complex potential overpayments and validate them via view-only access to your system. You get peace of mind thanks to technology-driven identification and expert validation. This extra step of human oversight  ensures proper confirmation of overpayments identified while protecting your valuable provider relationships. We’ll even provide full claim  documentation and detailed reports, so your team knows everything that we do.

Our vast array of capabilities includes COB, duplicates, contractual liability, CMS compliance, eligibility, exclusions, global services, billing errors, fee-schedule audits and more. We’ve identified billions of dollars in mispayment savings opportunities and are committed to your financial results and lowering the cost of healthcare.

Why this solution?

Lowers Costs

Our services reduce your total claims costs and administrative expenses.

Wide Scope Increases Savings

Our comprehensive solution identifies a broad range of overpayment causes and savings opportunities.

Ease of Use

We’ll make it easy on you and your team, so you can focus on other priorities.

Manual Validation Improves Quality

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

  • Data Mining
  • Analytics
  • Root Causes

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 millions 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.
  • Algorithms are augmented with 100% manual validation to verify 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.