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.
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)