Payment Integrity

Maximize recoveries and improve cost avoidance with an enterprise-level platform

Industries /Healthcare & Life Sciences /Health Plans /Payment Integrity

Improve Payment Accuracy With Next-Generation Intelligence

Challenges and pressure to reduce healthcare costs, increase recovery rates and avoid overpayments continue to rise. Health plans strive to improve payment integrity capabilities by transforming outdated technology and processes. But most point solutions lack transparency or only provide a one-sided view across business lines, which leads to increased administrative and medical costs. They also rely on retrospective pay-and-chase models with minimal intention to fix the root cause. It’s time to shift from the pay-and-chase model of payment integrity to a model that will enable near real-time accurate payments.

We can help. As a trusted global innovator, we assist health plans in harnessing next-generation intelligence and advanced analytics through our Medical Cost Manager (MCM). We combine advanced data management with Fast Healthcare Interoperability Resources (FHIR) integration for real-time data collection to bring a unified, holistic view of high data value points from claims and membership information. This approach provides a complete view with more transparency and insights to detect and prevent overpayments to improve cost avoidance. See what MCM can do for you.

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Medical Cost Manager helps increase overpayment identification, improve accuracy, reduce vendor spend and optimize operations.

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An Enterprise-Level Payment Integrity Solution

Processes diverse data sources through comprehensive, deep learning and custom rules enabled analytics to provide 360-degree view.

MAXIMIZE

Comprehensive platform with agility adapts and integrates with systems to respond to changing regulations

INCREASE

Advanced analytics and machine learning identify gaps and fixes the root cause for better cost avoidance

SIMPLIFY

360-degree member/claim view with capabilities customizes and integrates with diverse data sources

OPTIMIZE

Automation and command center with workflow reduce administrative costs and vendor spend for streamlined operations

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Shift Gears

Should you shift to an AI-powered payment integrity (PI) model? Our webinar explores the change in focus from payment platforms to a systemic use of automation to simplify the PI function. Experts from IPsoft and NTT DATA explain how you can leverage a self-driving PI program to improve provider satisfaction, reduce regulatory risk and achieve cost savings.

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Our Services

Claims Editing Platform

Evaluate claims for coding accuracy and integrate with claims workflow processing in real time, without human intervention.

Coding/Clinical Error Identification

Validate claims data using the platform and clinical analyst to identify inconsistent or incorrectly coded claims.

Consulting & Integration

Provide subject matter expertise support to streamline operations, adopt new technologies and grow your business.

Coordination of Benefits

Streamline recovery for commercial and government plans by using a 360-degree member review and innovative combination of unique algorithms and information from non-conventional data sources.

Overpayment Identification

Review paid claims files and apply data mining/grouping logic/algorithms to identify potential overpayments and provide insights into disbursement leakages.

Subrogation

Identify and coordinate primary payment of claims to prevent or reduce payment/overpayment.

Everest Group named us a Leader in Healthcare Payer Digital Services, citing our business-first approach and end-to-end services. – January 2020

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