Payer - Payment Integrity Audit Services

Recover your lost dollars through a retrospective review of paid claims

  • The total healthcare system waste is estimated to be $100 billion on an annual basis, with CMS estimates of approximately $65 billion in improper payments (through payment errors, waste & fraud)
  • It is estimated that 3-10% of health care funds are lost due to improper payments, not just fraud.
  • Payment variances run into millions of dollars per each Payer entity.

At a time when there is an increasing emphasis on minimizing healthcare costs & controlling wasteful expenditure, these payment variances are a heavy financial burden on the healthcare system. Data Marshall helps in preventing & controlling the incorrect payments, and reducing the instances of Fraud & Abuse through our Payment Integrity Audit services. Our 360o approach emphasizes on identifying and recovering incorrect payments made by the insurers, due to various reasons including incorrect Contractual reimbursements and Coordination of Benefits. Our Claim review ensures that the providing billing & coding are in compliance with the standards and capture the appropriate details.

Approach

  • Assist the Health Plans, Insurance Companies, Self-insured employers & TPA's to identify & recover overpayments on claims made to providers.
  • Retrospective review of paid claims to validate the appropriateness of the billing, coding & reimbursement of the claims.
  • Deep dive analysis of the claims to identify potential overpayments & provide key inputs & insights to the payers preventing future overpayments.
  • Comprehensive sweep on potential overpayments, either as a sole vendor, or as 2nd /3rd level vendors to complement & supplement the efforts of the existing vendors.
  • 360o retrospective review of paid claims, going beyond tool based insights & predictive analytics in identifying overpayments, augmented by deep-dive analysis.

Highlights

  • Pioneer in the Offshore Payment Integrity Audit services, with deep domain experience of over a decade in healthcare analytics.
  • Prevention of Fraud, Waste & Abuse through early warning signal systems.
  • 2nd pass review coming behind the existing vendors to identify overpayments & trends.
  • Concerted efforts on low dollar recovery.
  • Contingency based pricing model - zero upfront fees.
  • Minimal involvement of the client, allowing the client to focus on their core business.

case studies

Claims overpayment recovery services for a client located in Nashville.

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