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Payment Accuracy

increase claim payment integrity and cost containment

solve your toughest business challenges

Payers are constantly challenged to do more with less as they seek to pay accurately and efficiently for the proper care of their covered members. Verscend’s end-to-end Payment Accuracy solution is the ultimate solution for addressing payment integrity challenges across the full claim payment continuum.

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challenge:
reducing medical loss

the ways Verscend helps

  • Avoid paying improper professional and outpatient facility claims
  • Reduce improperly paid high-dollar inpatient facility claims
  • Prevent or recover lost dollars, even as FWA schemes evolve

challenge:
reducing administrative lift

the ways Verscend helps

  • Auto-adjudicate more claims
  • Decrease the burden on your clinical, technical, and SIU staff
  • Gain more savings opportunities while expending fewer resources
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challenge:
strengthening provider relationships

the ways Verscend helps

  • Reduce incorrect or unexplained denials
  • Shorten your time to address appeals
  • Avoid false FWA accusations

challenge:
maintaining compliance

the ways Verscend helps

  • Stay on top of federal, state, and industry guideline changes, and quickly translate them into business rules
  • Achieve savings faster and avoid penalties
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get more value from a proven leader

Being a payment integrity leader requires experience, scalability, innovation, and proven value. Verscend is that leader. We’ve spent 20+ years honing our products and services specifically to drive exceptional value for our clients all along the claim payment continuum. Our unique approach to pre-payment claim accuracy was the first of its kind two decades ago and remains a market-leading offering today.

Unwavering dedication to going beyond the status quo and delivering exceptional value has earned us more than 100 clients—from small third-party administrator plans to national payers, many of which have been with Verscend for over a decade.

medical cost savings*

In 2017, Verscend identified more than $2 billion in savings opportunities for our clients. Some individual client examples include:

  • $22 million in savings (5.59%) as the primary editor
  • $90 million in additional savings (1.3% of paid claims) as the secondary editor
  • $165 million in additional savings (3.4% of paid claims) as the secondary editor
  • $134 million in additional savings (0.7% of paid claims) as the tertiary editor
  • $3.9 million in overpayments identified on total inpatient charges of $21.3 million (18.3%)
  • 5:1 to 15:1 ROI on FWA detection and prevention

*Based on specific client savings reports. Individual results will vary.

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administrative efficiency

Verscend’s technology and services reduce the administrative burdens that often accompany medical cost savings measures. Examples include:

  • Implementation in as little as 90 days**
  • Avoidance of the administrative and operational costs of clinical content maintenance
  • Reduced effort around appeals and claim rework
  • Reduced provider abrasion from false positive allegations of waste or abuse
  • More time to investigate true cases
  • Reduced pay-and-chase

**Claim Accuracy can be up and running in as little as 90 days for a batch mode off-the-shelf implementation, with an average of about 120 days for real-time, depending on client resources.

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find your Payment Accuracy

a highly flexible, end-to-end solution for effective payment integrity

Verscend Payment Accuracy is one of the most effective and proven solution sets in the market for addressing improper healthcare claims payment and fraud, waste, and abuse (FWA).

We provide real-time, pre-pay claim accuracy and pre- and post-pay FWA solutions scalable for all sizes of payers. A convergence of data, technology, and analytics, our solutions can be used individually or together, in any combination. Each adds measurable value along the payment continuum.

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Claim Accuracy

Claim Accuracy is a unique pre-payment offering for increasing cost containment on improper professional and outpatient facility claims. The combination of SaaS editing technology and clinical claim validation services ensures the accuracy of claim payments, increases adjudication speed, and reduces health plan technical and clinical resource needs—all while causing no disruption to current workflow and no delay in payment to providers. Clients can also add our Inpatient Claim Accuracy services for a pre- or post-pay review of high-dollar fee-for-service hospital bills.

Interceptor

Interceptor identifies potential patterns of fraudulent or abusive claim submissions much earlier in the process than pay-and-chase activities. Identified patterns are analyzed and referred to clients well within prompt-pay requirements, avoiding costly fines and penalties.

Sentinel

Sentinel is Verscend’s post-payment system for automated detection of potential fraud cases, billing misunderstandings and mistakes, and non-adherence to medical policies. Top payers rely upon Sentinel to evaluate, compare, rank, and score providers and members. The resulting “Index of Suspicion” ensures that SIUs receive high-impact leads for cases.

Informant

Informant is an advanced data analysis tool that supports user-controlled exploration of healthcare data to discover irregularities and isolate questionable billing/payment patterns.

Commander

Commander is Verscend’s case tracking “command center” tool that helps build, track, and learn from FWA caseloads.

SIU Services

Verscend offers a wide range of program integrity services, from augmenting in-house staff with investigative support to providing a complete and comprehensive outsourced SIU.

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don’t just take our word for it

Here are just two recent examples of real client case studies.

reducing improper payments and provider abrasion

Background:
A Midwest-region health plan with commercial, Medicare, and Medicaid lines of business suspected that it was paying too many improper claims. The plan was applying standard, automated claim editing and post-pay review and recovery for some clinical situations, but needed a way to identify and review claims too clinically complex for auto-adjudication rules without holding up overall claim processing speed.

What happened:
The plan approached Verscend to apply Claim Accuracy’s clinical validation service as a second layer of pre- pay defense after applying “black-and-white” edits. Verscend was very quickly able to show the plan just how many improper claims were passing through its editing system, as well as the need for payment policy changes.

Results:
Because of Claim Accuracy, the client became more consistent with other payers’ payment policies, saw a significant reduction in provider abrasion and administrative hassle caused by its previous post-pay claim review, and ultimately realized significant avoidance of improper payments—to the tune of $4.6M incremental to that of its basic claim editing system.

alleged drug testing overpayment

Background:
A New York-based health plan used our Sentinel, Informant, and SIU Services solutions to detect patterns of FWA and provide support for building cases and improving recoveries.

What happened:
Sentinel detected a pattern of claims that flagged one provider for potentially violating the CMS‘s Medically Unlikely Edits (MUEs) and for ranking as the highest paid provider among peers for HCPCS code G0483 (Definitive Drug Testing). Verscend investigators then used Informant to determine that for more than two years, the provider in question had been paid $1.3M for codes G0481 through G0483. However, per New York State’s clinical laboratory procedure codes, only G0480 is recognized for billing Definitive Drug Testing. In fact, G0483 had been billed from this provider at a rate 10 times that of the second-highest billing provider in that specialty in the area.

Results:
With the Verscend FWA allegation details in hand, the health plan was able to confidently send a recovery letter to the provider requiring reimbursement for improperly paid claims.

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Ready to improve your payment integrity savings?
Contact us for a customized analysis of the savings Verscend can deliver to your organization.