Solutions

Solutions

A full portfolio of pre-payment

and post-payment solutions

We offer a growing portfolio of solutions to help you meet your cost containment goals.

DRG VALIDATION

The end of coding errors.

There exists a multitude of opportunities for error, resulting in overpayments. We’ve developed special expertise in validating DRG assignments—so you never have to overpay on claims paid via Diagnosis Related Groups.

We’ve built the most thorough and effective DRG Validation solution in the country. Its success is the result of:

 

 

Proprietary predictive analytics. Our PhDs and statisticians have built a sophisticated software system that leverages machine learning and advanced analytics to sift through claims to identify those meriting closer scrutiny. Better claim selection delivers better audit results.

 

 

Onsite auditing. By performing audits onsite, we get access to the full medical record and on-the-spot answers to questions. It enables us to develop personal relationships with providers—the kind of relationships that build trust and ensure ongoing cooperation. And working onsite affords us the opportunity to conduct larger audits that deliver greater savings.

 

Certified coders. All reviews are conducted by highly trained certified coders, employed directly with us, with a quarter-century or more of proven experience.

 

 

Signed overbilling acknowledgements. Upon completion of all audits, we obtain a signature acknowledging the overbilling from the provider. The signature facilitates the collection of the overbilled dollars and avoids further disputes.

 

For every claim reviewed, we either validate that the correct DRG code has been selected or suggest an alternative DRG code. If the latter, we provide an explanation with supporting documentation to the facility for review and sign-off.

Contact us today to maximize your DRG Validation savings.

 

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Outpatient Audits –
APC Validation

A growing opportunity to save.

As the healthcare business model shifts from volume to value, outpatient procedures are becoming a larger percentage of the provider care mix. The AHA estimates that 60% of surgeries are now outpatient — and that trend is expected to continue.

Outpatient services have complex coding with significant potential for overpayments. While individual outpatient claim overpayments are often less sizeable than those for inpatient care, the sheer volume of outpatient claims indicates that this is a significant, often untapped, opportunity for healthcare cost savings.

We enable you to seize the opportunity. Because outpatient coding and billing are different, we’ve developed special outpatient claims analysis software that enables us to pinpoint potential overpayments quickly and efficiently.

For you, it’s one more reason to entrust your claims auditing to the provider that knows you best and delivers more savings—OmniClaim.

Contact us now to learn more about our Outpatient Validation solution.

 

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Carve-Out Audits – Implantable Audits

Ensure that contractual terms are honored.

As the number of carve-outs has grown, it has become increasingly challenging for payers to ensure that hospitals adhere to the terms of their contracts. While acute care providers look to implantable devices to bolster their profitability, payers must be vigilant to avoid excessive costs.

We have been conducting Carve-Out and Implantable Audits for more than a decade. Our Carve-Out Audit solution resolves key challenges by ensuring that providers bill payers accurately and in accordance with contractual terms.

Contact us today to lower your costs related to carve-outs.

 

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High-Cost Drug Audits – Rxi Audits

Keep specialty pharmaceutical costs under control.

High-cost drugs and injectables are a major expense for payers – and an area that can easily result in costly overbilling due to inaccuracies in dosage, frequency, length of therapy, and non-compliance with contractual payment terms.

Our audits identify overpayments in a variety of areas, including:

 

Contract inaccuracies – high-cost drugs are often given specific payment terms in a contract, which are not always strictly adhered to.

 

 

High-billed units – units that exceed the Medicare/Medicaid MUE or the clinical recommended maximum dosage.

 

 

Orders, units, and time – these details need to be closely reviewed for errors.

 

 

Drug/diagnosis comparison – drugs that do not have related diagnosis codes.

 

 

Multi-dose vial analysis – medications billed as a full vial when available as a multi-dose vial.

 

 

Claim line paid amount outliers – when the paid amount for HCPCS/DOS differs from all instances of billing for the same Patient/HCPCS code.​

 

Contact us today to ensure that high-cost drugs aren’t costing your bottom line.

 

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Data Mining

The fastest route to cost containment.

 

Complex contracts. Multiplying codes. Cumbersome processes. It’s inevitable that payment errors occur – and they’re costing payers like you millions of dollars every year.

We can confirm the accuracy of all paid claims – and detect claims that have been overpaid – with our Data Mining solution. Taking advantage of advanced analytics and predictive modeling, our Data Mining solution ensures that all claims have been processed correctly and in accordance with contract terms. It uncovers overpayments in all key areas, including:

  • Retro-terminations
  • Eligibility
  • Duplicate payment
  • Coordination of benefits
  • Misapplied contract terms/contract compliance
  • Violations of payment policies
  • Contract compliance
  • NCCI edits
  • Medically unlikely events
  • Bundling and unbundling
  • Readmissions

 

While it consistently and reliably identifies payment errors, our Data Mining solution provides additional benefits:

 

Fast implementation. We can get your Data Mining program operational in as little as two weeks.

 

 

Future error minimization. Our Data Mining solution not only identifies overpayments, but also helps you identify repeat errors. This can lead to remedial actions to prevent future errors and ensure more correct claims payments.

 

Our Data Mining program saves millions of dollars annually. Contact us today to accelerate your cost containment efforts.

PROFESSIONAL NEGOTIATION

All claims. All sizes. Signed agreements. No waiting.

As PPO membership grows and specialty providers proliferate, the rate of out-of-network, non-discounted claims can increase—requiring you to pay reimbursements far in excess of in-network rates.

Our comprehensive Professional Negotiation solution uses benchmark data gleaned from our proprietary databases and well-trained experts who negotiate all of your out-of-network, non-discounted claims to obtain a signed agreement on every claim under the best possible terms.

Data-driven and built on case-specific strategies, our Professional Negotiation solution offers several benefits:

 

 

We negotiate all claims—not just the large ones.

 

 

We obtain a signed agreement on every claim.

 

 

We accept claims from our clients in any format.

 

 

We work to complete negotiations promptly.

 

For you, it adds up to substantial savings with zero hassle. Contact us now to discuss your Professional Negotiation needs.

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