Payment Accuracy

increase claim payment accuracy and cost containment

solving the toughest payer 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 integrated, end-to-end Payment Accuracy solution is uniquely qualified to help payers solve their toughest business challenges.


Reducing medical costs

the ways Verscend helps

  • Avoid paying improper professional and outpatient facility claims
  • Reduce improperly paid high-dollar inpatient facility claims
  • Prevent evolving fraud and abuse

results Verscend can deliver

  • An incremental 1% to 6% savings from annual professional and outpatient facility claim spend
  • 18% savings off improper high-dollar inpatient charges
  • $0.40 to $1.70 per member per month savings from fraud prevention

Reducing administrative costs

the ways Verscend helps

  • Auto-adjudicate more claims
  • Decrease the burden on your clinical and technical resources
  • Relieve SIU investigators of time wasted on false positives
  • Implement more opportunities with less lift

results Verscend can deliver

  • >95% auto-adjudication rates
  • 65% less time wasted on false positives
  • Lower total cost of ownership
  • Lower implementation cost and faster time-to-market

Maintaining provider relationships

the ways Verscend helps

  • Reduce incorrect or unexplained denials
  • Shorten your time to address appeals
  • Avoid false accusations of fraud, waste, and abuse

results Verscend can deliver

  • Satisfied physicians and improved mutual trust

Complying with national and state payment guidelines

the ways Verscend helps

  • Stay on top of industry guideline changes, and quickly translate them into business rules

results Verscend can deliver

  • Avoided cost from late or missed edit deployment
  • Avoided penalties

delivering an integrated, end-to-end approach for maximum savings

Verscend Payment Accuracy is the industry’s only real-time, pre-pay, integrated claim accuracy and fraud detection solution scalable for any size of payer. A convergence of technology, data, and analytics, our solutions incorporate a unique element: expert clinical review, a process that drives the increased accuracy of claims payment.

efficient technology for administrative ease

A customizable software-as-a-service (SaaS) platform allows Verscend to deliver solutions that meet our clients’ unique business needs, minimize their technology resource costs, and speed up implementation and maintenance to realize value more quickly. Implement just one of our solutions and you set up the infrastructure to quickly turn on other solutions when ready, reducing total implementation costs. Our enterprise Java and web services create seamless, real-time claim processing connections with payer and third-party systems, avoiding claim payment delays.

clinical analytics expertise that drives success

Licensed registered nurses, certified clinical coders, and fraud analysts work collaboratively with data scientists to develop and maintain millions of claim edits, hundreds of suspect behavior algorithms, and several layers of predictive analytic models. These same experts also clinically review our clients’ claims and flagged provider billing patterns, rendering recommendations before payment. This process makes Verscend unique in the industry and particularly adept at identifying more savings opportunities.

powerful results for your medical cost management

Our combination of advanced analytics, technology, and expert human touch prevents inappropriate payments before they are made and helps increase the speed and likelihood of post-pay recoveries. In 2016, Verscend identified $1.5 billion in savings opportunities for our clients.

Our clients save anywhere from $1 to $4 or more per member per month.


the Verscend difference

  • One implementation (generally 90 to 180 days) will allow you to deploy any or all of our solutions.
  • A truly integrated pre- and post-pay offering allows synergy between claim operations and the SIU.
  • Ours is the only fraud analytics solution to employ clinical investigators that reduce the SIU’s false positive research time by 65 percent while handing over actionable referrals that are accepted by clients an average 85 percent of the time.
  • Claim Accuracy is unique in the market because it can run as a primary, secondary, or tertiary editing system utilizing a mix of machine-driven rules with near-time nurse review to ensure proper adjudication of complex claims.
  • Our fee structure is the most flexible and competitive in market, with a combination of license fee and percentage of savings.
  • We have experience and scalability across the payment continuum, with results on more than 50M lives.

Verscend value

  • Contain more medical costs*—individual client results include:
    • $22 million in savings (5.59 percent) as the primary editor
    • $90 million in additional savings (1.3 percent of paid claims) as the secondary editor
    • $165 million in additional savings (3.4 percent of paid claims) as the secondary editor
    • $134 million in additional savings (0.7 percent of paid claims) as the tertiary editor
    • $3.9 million in overpayments identified on total inpatient charges of $21.3 million (18.3 percent)
  • Implement in as little as 90 days**
  • Avoid the administrative and operational costs of clinical content maintenance
  • Reduce provider abrasion over denied claims
  • Reduce false positives, leaving more time to investigate true cases and improving provider relationships
  • Create a deterrent effect by using outside subject-matter experts to review claims

solutions that add incremental value along the payment continuum

We offer each of our Payment Accuracy solutions standalone or as part of the end-to-end suite.


Claim Accuracy
increase accuracy, efficiency, and cost containment

Verscend Claim Accuracy offers a complete payment approach that optimizes your claim processing and increases cost containment on improper professional and outpatient facility claims. We combine SaaS editing technology and clinical claim review services to ensure the accuracy of claim payments, increase adjudication speed, and reduce health plan technical and clinical resource needs—all while causing no disruption to your current workflow and no delay in payment to your providers.

Our automated claim editing integrates with your current claim system to ensure the accurate coding of claims before you pay them. We apply our more than 17 million nationally sourced, customizable claim edits in sub-second real-time or batch mode to identify claim coding or payment policy violations, helping to increase auto-adjudication rates.

More complex claims that can’t be auto-adjudicated run through a second rules engine for flagging of improper state-specific Medicaid coding, modifier 25 and 59 misuse, cross-provider duplicates, and more. Our team of clinicians, nurses, and certified coding experts then validates the claims, makes payment recommendations within hours, and supports you through appeals.

Licensed registered nurses and AHIMA- and AAPC-certified coders constantly monitor standards organizations, such as the Centers for Medicare & Medicaid Services and the American Medical Association, to get edit updates and changes into production quickly. Our staff can easily customize edits for your reimbursement policies and exceptions.

With our SaaS model, there are no associated hardware costs or client technical staff support needs. Implementation and maintenance are fast, so you can realize value more quickly. We save you time while ensuring your staff and providers have excellent visibility into the source author, detail, and text for each edit message, helping to reduce appeals.

One Verscend client recently saved $165 million from its annual claim spend incrementally to the client’s primary claims editor.


Fraud Detection
reduce the costs of fraud and abuse

Verscend Fraud Detection combines advanced analytics and clinical investigative review to deliver actionable case referrals to health plan cost containment staff and special investigations units (SIUs). The result is pre- and post-pay protection from aberrant billing and known and emerging fraud schemes.

Multiple levels of proprietary analytics run on a variety of data sources to flag potentially bad billing behavior, which is then thoroughly reviewed by our clinical investigative unit (CIU). Our analytic-driven allegation referrals are then delivered via a true production application, which our own CIU and the plan’s SIU use together to drill down into the data for greater detail. Allegation summaries provide a clear presentation of all facts, including suspect providers and their behavior, visualization to help conceptualize the findings, a list of patients associated with each allegation, and recommendations for further action.

Our optional case tracking tool is a comprehensive and highly customizable workflow management tool and information repository offered as an ASP solution, minimizing the SIU’s administrative time and resources needed for complex investigative case tracking and reporting to law enforcement.

Clients may also select our optional SIU chart review services to augment their staff.

Clients that self-report Fraud Detection results to Verscend show savings of between $0.40 and $1.70 per member per month.


Inpatient Accuracy
reduce improper high-dollar inpatient claim costs

Verscend Inpatient Accuracy performs a combination of claim editing, clinical validation, and complex claim review of high-dollar fee-for-service hospital bills. Although these claims may only compose 1 to 2 percent of typical inpatient claims, they often represent 5 to 12 percent of inpatient costs.

We use advanced analytics and human expertise to validate that these bills are coded and paid appropriately. Our certified coding experts then review the claims, reconstruct the course of care from a clinical perspective, and identify any differences between the care provided and the charges billed. If the hospital appeals our recommendations, our experts support you through the appeals process. For any recommendation that we overturn after review of additional documentation, we will credit back any overturned savings that were invoiced.

Verscend saved one client $3.9 million on total identified charges of $21.3 million (18.3 percent) in 2015, and another $2.2 million on $13.6 million in total charges (16.3 percent) in 2016.


Dental Accuracy
reduce the costs of dental fraud, waste, and abuse

Verscend Dental Accuracy is a full-service offering of dental claim editing, clinical validation services, consulting, and fraud detection. After applying automated edits on such billing situations as unbundling of codes, global follow-up periods, age limitations, frequency of services, and other scenarios based on plan language, claims requiring manual review are pended for our dental clinical review workflow. Verscend’s dental coders and specialists perform clinical review and return payment recommendations to the client within hours of receipt and processing into Verscend’s systems. Verscend’s licensed dentists also perform dental consultant review when claims require additional clinical analysis or medical necessity review.

Dental fraud profiling takes place in parallel with claim editing and review, consisting of analysis and scoring of provider billing behavior to identify potentially fraudulent billing patterns and adjust edit scrutiny accordingly.

Verscend’s automated editing logic and clinical review payment recommendations are sourced from nationally recognized coding standards to ensure that denials and reductions are defensible. In cases where providers appeal these decisions, Verscend’s clinical experts process appeals on behalf of clients, providing additional explanations to support our coding and payment recommendations.

Verscend saved one client $417,000 on analyzed paid claims of $22 million (1.7 percent) in 2015 from Dental Accuracy’s claim editing and clinical review capabilities alone.


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