Payment Integrity

Capture more revenue and reduce inappropriate claims payments

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

Today’s complex health plan environment opens the door for payment integrity issues, including Fraud, Waste, and Abuse (FWA), because you must analyze huge data loads, coordinate payments to multiple carriers and manage a wide range of health plans across government and commercial clients. FWA leads to higher costs for you – and higher co-payments and premiums for members.

We, along with our strategic partners, deliver solutions that use workflow automation and dashboards so you can proactively detect and investigate non-payable claims. We can help you capture more revenue and automate payment authorizations with proven toolsets for screening, scoring and coordinating benefits. Our solutions allow you to improve pre-pay screening and scoring for direct savings and scan for program irregularities and billing anomalies. Plus, you can use advanced analytics to improve audit and recovery results and increase referrals using provider risk scorecards.

Capture more revenue and automate payment authorizations with proven toolsets for screening, scoring and coordinating benefits so you can improve payment integrity and boost revenue recoveries.

We can help

Automate coordination of benefits with other carriers to verify eligibility, coverage, and coding

Comply with federal and state regulatory mandates

Provide dynamic reporting of multiple performance indicators through automated workflow and dashboards

Implement effective detection, investigation, and recovery services

Our solutions:

Reduce Fraud and Waste
Rapidly identify aberrant providers, track member behavior, and use powerful analytics to interrogate pre-payment claims. Services include prepay clinical reviews before payment, forensic coding and predictive analysis, incident analytics and reviews, and investigative support.
Coordination of Benefits
Automate coordination of benefits with other carriers to verify eligibility, coverage and coding, as well as identify overpayment, recoveries or claims paid inappropriately. We can help with verification, accurate identification between primary and secondary payers, expedited recovery and claims re-verification.
Orchestrate accurate recovery and payments from a variety of information sources through improved data mining and billing. Our services feature secure 24/7 Internet access, real-time updates, paperless process via imaged documents and automated prompts that drive workflow.
Third-Party Recovery
Identify and coordinate the responsible party for primary payment of claims to prevent or reduce payment/overpayment of claims. Services include proprietary data mining techniques applied to identify member coverage with other carriers, recovery via direct billing or disallowance and case management of all coverage information to avoid paying claims when another party is liable.
Utilization Management
Control the authorization and best use of benefits through licensed care managers, nurses, physicians and other key clinicians. We provide standard week-day call center, with urgent call center available 24/7 for weekend emergency pre-certifications and appeals. In addition, we provide experienced case/care management nurses with active licensure in the state of practice, diverse medical backgrounds and at least five years clinical experience. Our intake coordinators have four-year degrees, prior call center experience and/or medical coding/terminology knowledge.
Consulting and Integration
Provide ongoing support and subject matter expertise to analyze existing or needed systems for client-specific industry-leading solutions. Solution features business process management system dashboards, review of existing systems and data and system integration services.