At ClaimInformatics, we love acronyms and also love to combine advanced analytics with proactive action to drive down healthcare costs for self-funded plans. Our innovative OPTIMIZE (Operational Precision to Maximize Integrity, Transparency, and Efficiency) ensures compliance with the Consolidated Appropriations Act (CAA) and ERISA fiduciary responsibilities, offering meaningful financial returns and comprehensive oversight.
OPTIMIZE: A Two-Phase Solution
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.
100% of Claims
Whereas other payment integrity firms look at only a small targeted set of data, we review every claim prior to payment or that has been paid. Nothing falls through the cracks with ClaimInformatics.
Continuous Improvement
We are continuously supplementing and refining our hundreds of proprietary algorithms, which enable us to catch fraud, waste, abuse, and mistakes at a rate five times the industry average.
Episode of Care Logic
With incredible accuracy, our exclusive Episode of Care Logic™ acts as a detective to identify claims where the wrong service code was billed.
Phase 2: 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, and Utilization Safeguard
PROOF: Pre-Payment Observation & Oversight of Fiduciary
FOCUS: Fiduciary Oversight, Compliance, and Utilization SafeguardFOCUS is designed to ensure your health plan meets fiduciary requirements under ERISA, aligns with industry best practices, and mitigates risks. This phase involves a detailed evaluation of plan governance, ensuring participant interests are protected and compliance gaps are addressed. FOCUS provides 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.
“I have taken a hard look at every payment integrity vendor out there. And ClaimInformatics is, bar none, the best provider I have seen. Their platform is incredibly advanced, and their ability to recover on plan assets also sets them apart. They don’t just review data – they deliver actionable results that provide their clients with the confidence that they are being excellent financial stewards. I wish I had this during my tenure at Health and Human Services.”
- Gary Alexander, Former Secretary Health and Human Services of Rhode Island,
Medicaid Director of Rhode Island, and Secretary of Human Services in Pennsylvania