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The Challenge

Commercial – Payment Integrity

³ÉÈËÊÓƵ analysis uncovered opportunities for a third-party administrator using a variety of PPO networks to:

• Improve payment accuracy – too much was being missed in the existing editing process
• Gain control over clinical billing waste and abuse
• Minimize provider abrasion to preserve leased network relationships

The Solution

³ÉÈËÊÓƵ implemented a provider-mindful payment integrity process that balances action with evidence:

• Claim Correction service to catch errors missed by the primary editor
• Audit Alert service to enable targeted examination of medical records pre- or post-payment

The Results

³ÉÈËÊÓƵ’s Payment Integrity program helps the TPA to deliver greater accuracy and lower medical cost without undue provider pushback:

• Additional 1% medical cost reduction from claim correction
• Less than 1% of corrected claims lead to provider appeal
• Nearly 1% of paid dollars flagged for audit due to more complex errors