OPTIMIZE:
A Comprehensive Fiduciary Solution
At ClaimInformatics, we understand the challenges self-funded employers and their fiduciaries face in maintaining health plan oversight. Our OPTIMIZE solution offers a structured, two-phased approach to address these challenges, combining deep analysis with actionable solutions.
This comprehensive strategy begins with uncovering inefficiencies and areas of concern through the PAIR report, followed by targeted corrective actions using FOCUS and PROOF. Together, these phases ensure your plan is compliant, cost-effective, and aligned with fiduciary responsibilities.
Phase I: The PAIR Report
(Plan Accountability & Integrity Review)
Our initial analysis provides a detailed examination of your plan’s spending, highlighting:
-
Overpayment Identification: Pinpointing claims where the plan overpaid.
-
Administrative Services Review: Scrutinizing the transparency and fairness of your ASO/ASA agreements.
-
Error Detection: Identifying improper billing practices such as unbundling, upcoding, and duplicate payments.
-
CAA Compliance: Ensuring adherence to the Consolidated Appropriations Act requirements.
Key Findings & Solutions
The PAIR Report categorizes findings into three tiers based on severity and actionability:
-
Tier I Findings: Overpayments that can be recovered from providers.
-
Tier II Findings: High-probability errors requiring further verification.
-
Tier III Findings: Unusual claims that warrant additional scrutiny.
Sample Detailed Analysis:
-
Total Claims Analyzed: $652.9 Million
-
Potential Overpayments: Up to 19.2% of claims
Example Findings:
-
Improper Coding: Billing for more complex procedures than were performed.
-
Duplicate Payments: Multiple payments for the same service.
-
Non-compliance with Network Policies: Claims paid without applying negotiated discounts.
Phase II: Corrective Action
with FOCUS & PROOF
Once the PAIR report identifies areas of concern, OPTIMIZE transitions to implementing corrective actions through two distinct services:
-
FOCUS (Fiduciary Oversight, Compliance, & Utilization Safeguard): This service ensures your plan meets fiduciary requirements under ERISA, aligns with best practices, and mitigates future risks. FOCUS helps streamline plan governance, protect participant interests, and ensure ongoing compliance.
-
PROOF (Pre-Payment Observation & Oversight of Fiduciary): As a pre-payment solution, PROOF prevents improper claims payments before they occur. By combining advanced analytics with expert intervention, PROOF safeguards plan assets and enhances the financial health of your organization.
FOCUS: Fiduciary Oversight, Compliance, & Utilization Safeguard
Adherence to ERISA &
the Consolidated Appropriations Act (CAA)
FOCUS ensures your health plan aligns with fiduciary requirements under ERISA, adheres to industry best practices, and minimizes risks. Through a comprehensive evaluation of plan governance, FOCUS protects participant interests while identifying and addressing compliance gaps.
By partnering with your Network or TPA, ClaimInformatics ensures plan assets are managed according to plan documents. With FOCUS, you receive ongoing support to:
-
Strengthen fiduciary accountability.
-
Implement strategies to reduce overpayments and mismanagement.
-
Establish a sustainable framework for compliance and oversight.
PROOF: Pre-Payment Observation & Oversight of Fiduciary
PROOF takes a proactive stance to prevent improper claims payments before they occur. This pre-payment solution leverages advanced analytics, real-time reviews, and expert intervention to:
-
Safeguard plan assets by identifying potential errors or fraud prior to payment.
-
Enhance the financial health of your organization through precise, data-driven corrections.
-
Provide peace of mind by ensuring only accurate and legitimate claims are processed.
Why We Stand Apart
Our Platform
Our sophisticated coding and data mining capabilities use a fully-integrated rules-based engine to capture all national coding and payment guidelines applicable for state, federal, and private health plans.
Our proprietary Episode of Care logic eclipses all other reviews.
Our Independence
Healthcare is fraught with conflicts of interest, like “payment integrity” providers that are owned by the insurance companies they’re supposed to monitor. ClaimInformatics is different; we are fully independent, with an emphasis on serving plans and members.
Our Focus On The Members
ClaimInformatics is the only post-payment program that returns money to the plan and identifies member overpayments. The plan recovers funds, and our clients bring real monetary wins home to their members.
Unlock the Secrets in your Data
By leveraging OPTIMIZE, you can ensure your health plan operates with maximum efficiency, compliance, and cost-effectiveness, fulfilling your fiduciary duties under ERISA and adhering to the CAA requirements. Transparency is here, and we help you use it to your advantage to drive down costs while holding parties accountable.