Claims Auditing, Recovery, and Revenue

In today’s constantly changing health care environment, health plans and risk-bearing organizations (RBOs) are challenged to provide high quality care while sustaining operational costs and reducing expenses.

The claims processing cycle is a key area that can significantly impact your organization’s bottom line. Many organizations have sophisticated claims systems, but are unaware of exposure points that can lead to payment errors.

Our professionals have provided claims audit and recovery services for more than 40 years, consulting a range of managed care organizations, from multistate health maintenance organizations (HMOs) and insurers to regional Medicare and Medicaid plans, capitated medical groups and independent practice associations (IPAs), management services organizations, third-party payers, and accountable care organizations (ACOs).

Audit Processes

Auditing claims can help your organization determine how well it’s performing and where payment errors take place. During a claims review, we can test for:

  • Contract rate pricing
  • Division of financial responsibility (DOFR)
  • Co-pays, deductibles, and out-of-pocket maximums
  • Duplicate claim payments including fee-for-service capitated services
  • Coordination of benefits and third-party liability
  • Correct coding initiative (CCI) edits
  • Member eligibility
  • Authorized services

Payment Recovery and Benefits

We’ve helped RBOs obtain tens of millions of dollars in revenue from overpayments. By detecting and identifying errant claims through our unique process, our custom methodologies can help recover appropriate overpayments back to your organization. Our clients have historically experienced a return on investment of five to one or more in savings.

We work collaboratively with your organization to support cost containment activities and help process claims as accurately and efficiently as possible. We not only identify errors in claim audits, but also seek out the root cause so your claims team can understand the underlying basis for any errant claims.

We’ll help design recommendations and implement process improvement initiatives including training department staff, developing production tools, updating your claims system logic, and other remediation activities to prevent errors from occurring again.

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