Payers today face massive financial losses and are challenged to accurately identify and recover overpayments resulting from a complex and rapidly changing healthcare delivery system and reimbursement environment. A host of factors, including the rapid introduction of Specialty Pharma drugs, a rise in families with multiple coverage, State & Federal policies, and complicated billing procedures, have made it more difficult for payers to manage overpayments and control administration costs. These are some of the challenges that have resulted in both rising healthcare costs and an increase in the shifting of costs. They have also created the need for an effective solution to address overpayments holistically.
Today’s claims require highly complex adjudication that is sometimes outside the scope of traditional adjudication systems. Some legacy systems, for example, cannot be programmed to process complex reimbursements. Key areas that significantly contribute to overpayments include COB, Specialty Pharma, E&M, and implantable devices. The application of specialist knowledge by intensive manual review is required to identify, recover, and prevent overpayments in these high-impact areas.
- US Payers pay billions of dollars in overpayments each year
- Complex adjudication, contracts, reimbursements, and carve-outs make it difficult to identify and pend claims in pre-payment
- Traditional systems with limited billing/process standardization may make the systems incompatible or unable to accept complex contract requirements
- Increasingly system COB/Eligibility Related Overpayments
- Expensive to build software systems dedicated to performing overpayments
- Lack of adequate internal resources to maximize in-house cost containment programs
- Lack of robust systems to identify erroneously paid overpayments and limited billing/ process standardization makes the process to identify and recover overpayments difficult
SCIOinspire’s General Overpayment Recovery Services enable health plans to identify a broad range of overpayments that include duplicates, contracts, and CCI edits. Our software based data-mining capability, built on flexible architecture, helps to identify a wide range of duplication and claim adjudication errors. Our certified coders/examiners, pharmacists, and clinicians conduct manual data review to help identify and validate complex errors that may warrant additional research.(learn more)
SCIOinspire offers specialized programs for identification and recovery on complex claims that require expert manual reviews. These programs can help identify upto $23 PMPY. We leverage our hybrid teams, expert manual review to help payers go beyond their existing general overpayment programs and recover on specialized areas such as Specialty Pharma, COB/Eligibility, Implantables and E/M.(learn more)
- Specialty Pharmaceuticals: A customizable program that identifies recoverable specialty Pharma related overpayments. The program has built-in systemic overpayment identification, flagging, reporting, and process improvement recommendations to assist clients in efforts to reduce or eliminate future overpayments.(learn more)
- COB/Eligibility post payment services: SCIOinspire offers unique analytic services to establish an eligibility-related history of members and to perform an in-depth manual analysis to identify and recover overpayments typically recovering on areas such as COB adjudication errors, ESRD, Medicare, and Retro/Group terminations.(learn more)
- Implantable Devices Program: We help payers identify and recover claim overpayments for implantable devices. Our program helps clients to identify and address weaknesses in their facility contracts, and provides an overall cost-containment strategy.(learn more)
- Evaluation and Management Services: SCIOinspire collaborates with Payers and helps them to measure the extent of overpayment related to E&M billing abuse & errors. We then assist payers in taking the steps necessary to recover past overpayments and to prevent them in the future.(learn more)
