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.
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.
In 2017, Verscend identified more than $2 billion in savings opportunities for our clients. Some individual client examples include:
*Based on specific client savings reports. Individual results will vary.
Verscend’s technology and services reduce the administrative burdens that often accompany medical cost savings measures. Examples include:
**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.
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.
Here are just two recent examples of real client case studies.
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.
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.
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.
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.
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.
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.