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.
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.
ClaimInformatics identifies previously improperly paid claims and recovers those assets on behalf of the plan. We manage the entire process from identification to deposit.
This phase of our process acts as a feedback loop by identifying vulnerabilities in your existing pre-payment filters and payments systems, recommending gap-closing measures for more accurate front-end processing.
Best of all, ClaimInformatics clients only pay a percentage of amounts successfully recovered.
In a pre-payment environment, ClaimInformatics can deny suspect service codes before you or your members pay a cent.
Using more than 3 million industry-standard rules, coupled with hundreds of proprietary algorithms,
we analyze your claim submissions in real-time
to ensure billing and coding compliance.
While a good post-payment solution can recoup money that was already spent, the best way to protect your members and the plan is to prevent improper payments from ever occurring.
And with our ROI guarantee, embedding the ClaimInformatics pre-payment solution is no-risk, and provides safe-harbor under ERISA.
“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
Why We Stand Apart
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 embedded Episode of Care logic eclipses all other reviews.
Healthcare is fraught with conflicts of interest, like “payment integrity” providers being owned by the insurance companies they’re supposed to monitor, thus getting paid for fixing their own mistakes. ClaimInformatics is different; we are fully independent. We intentionally do not work with insurers, so our sole allegiance is only to the plans and the members we serve.
Our Focus On The Members
The plans who hire ClaimInformatics are beholden to their members, and we share that commitment. While our post-payment solution returns money to the plan, we are the only firm that identifies and reports member overpayments. We give our clients real monetary wins they can bring home to their members.