Healthcare & Pharmacy Claim Review & Recovery Solutions

The case for healthcare & pharmaceutical claim review: the United States spends over $3.3 trillion annually on healthcare. The National Health Care Anti-Fraud Association (NHCAA) estimates that 3% or $99 billion of all healthcare spending is improperly paid due to fraud. In addition, the American Medical Association has reported that 19.3% of all healthcare claims are not paid according to contract. Healthcare claim review and recovery services help your organization to pay accurately the first time. As a result, your cash flow is better managed.

 

The Centers for Medicare & Medicaid  Services report that 11% of their annual $1.2 trillion spends is paid improperly.

 

Given the magnitude of these statistics, the waste is staggering and ClaimInformatics can assist you in identifying and recovering your share while developing corrective action plans for your organization.

Claim Review

Medical care providers are experts at what they do, but they face an extremely complex payment system. When it comes time for them to invoice, providers make mistakes while navigating the cumbersome medical billing and coding landscape. Typical pharmacy contracts lack transparency, resulting in error-prone, complex pricing models.
The results: improper payments. 

 

Free Identification of Errors ClaimInformatics sorts through the complexities, uncovers the errors and processes improper payments for reimbursement. A complete forensic review of 100% of your transactions will be conducted to re-adjudicate and identify improperly paid claims. We’ll submit claims for reimbursement. Since we understand what healthcare providers are looking for, our requests for reimbursement are less likely to be challenged.

Safe Harbor

Our Safe Harbor program offers fiduciary oversight by helping deliver protection and excellence in plan oversight through independent governance and monitoring. This Safe Harbor program avoids conflicts of interest and benefits both members and the plan while mitigating employer fiduciary and personal risk and offering access to critical fiduciary oversight.

 

The Safe Harbor program adds another layer of plan administration services and creates additional accountability and transparency that is especially appreciated during renewal periods. We can’t stress enough the great value and peace of mind from mitigated risk.

 

The plan has a two-tiered pricing model with identification and reporting based on a per member per month fee and recovery and reconciliation on a percentage of recovery or alternative additional per member per month fee.

Post Payment Recovery

We stay engaged past the identification stage. Our collections team takes over, recovering improperly paid claims. Our process is designed for results. Best of all, you don’t owe us anything. ClaimInformatics clients only pay a percentage of recovered amounts, ensuring alignment of goals.

Corrective Action Plans

ClaimInformatics understands that in order to be part of the solution, we must invoke change and not be satisfied with the status quo. During our review, we identify vulnerabilities in your existing payment system. We’re able to use your data, coupled with industry knowledge, to design and implement a more accurate front-end process to reduce future improper payments.

Comprehensive Pharmacy Review

We review the performance of your Pharmacy Benefit Manager (PBM) to ensure that actual bills and rebates match contractual obligations. Then, by combining healthcare and pharmacy, we identify issues that might be overlooked by looking at claims in isolation. In addition, we recommend areas of opportunity.

End-To-End Solutions

ClaimInformatics uses advanced technology, full comprehension of the newest regulations and an expert staff to identify and recover improper payments. Our end-to-end solution incorporates state-of-the-art HIPAA compliant technologies designed to identify and recover improperly paid healthcare claims. Our Co-Founders have brought procedures and methodologies that have been refined over 25 years to yield high identification and recovery rates and low appeal rates.

 

No matter the size or client type we can take any unstructured healthcare claims data and turn it into a meaningful asset, that puts actual spent dollars back into your organization’s and your members’ pockets.