Claim Accuracy

pay claims accurately and reduce costs

the facts

Medical and administrative cost containment continue to be top of mind for payers. Aging members with growing illness burdens and increases in unit cost of care and overall utilization all play a part. Accurate and efficient claims payment is a priority, but achieving this goal while balancing resource constraints and avoiding provider disruption is a challenge for most plans.

Verscend Technologies offers a complete claim accuracy approach that optimizes your claim processing and increases cost containment on improper professional and outpatient facility claims. We combine software-as-a-service (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. Our approach causes minimal disruption to current adjudication work ow and payment to providers.

benefits

  • Increase the policy compliance and accuracy of claim payments
  • Reduce medical and administrative costs
  • Improve provider relations
  • Redistribute valuable clinical and IT resources

claim editing for increased accuracy and efficiency

In Verscend’s Claim Accuracy solution, the first line of defense is an automated editing platform. Integrated with your claim system, the platform ensures the accurate coding of claims before you pay them. Clients have seen savings on average of three to six percent of annual paid professional and outpatient facility spending.

Verscend applies 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.

A team of licensed registered nurses and certified clinical coders constantly monitors standards organizations, such as the Centers for Medicare & Medicaid Services and the American Medical Association, to quickly incorporate edit updates and changes into production within our system, so your team can focus on other activities.

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. Our staff can easily customize edits for your reimbursement policies and exceptions. At the same time, your staff and providers can view the source author, detail, and text for each edit message, helping to reduce appeals.

As just one example of our value, a Verscend client recently saved $165 million from its annual claim spend incrementally to the client’s primary claims editor.

clinical validation that further reduces improper payments

More complex claims that cannot be auto-adjudicated and are pended for review route through our proprietary workflow to clinical experts, who validate flagged claims in a matter of hours. This unique process further reduces your medical costs related to wasteful or abusive billing without disrupting payment. On average, we catch an additional one to three percent of total annual claim spending that might otherwise pass through adjudication.

Advanced algorithms, applied to nationally sourced and proprietary edits, flag potentially incorrect claims. Our team of clinicians, nurses, and certified coding experts then makes payment recommendations within hours and supports you through appeals. Types of edits include state specific Medicaid guidelines, modifier 25 and 59 use, cross-provider duplicates, and more.

Ours is the only claim editor on the market that supports same-day clinical validation of coding and addresses state-specific Medicaid managed care payment policies and guidelines.

collaborative support for additional value

Our Claim Accuracy solution is not a black box. We employ a personal touch to guide you through results, ensuring that you are trained, knowledgeable, and empowered to maximize value. The solution comes with dedicated post-launch support that includes in-depth standard and ad hoc reporting, as well as consultative reviews of claims data to determine return on investment and recommend best practices. Our experts partner with you to customize editing logic to maximize cost savings and conform to your reimbursement policies.

a single integrated implementation for flexibility and future savings

Claim Accuracy is part of Verscend’s suite of end-to-end Payment Accuracy solutions. Because the solutions all share one data feed across integrated platforms, clients can take a prioritized, incremental approach to rolling out our full suite, with only one implementation process required. In other words, once you have one component up and running, the others can be added simply by turning them on. This approach allows you to launch new capabilities faster while saving you money.

back to top

claim accuracy flowchart

Get this fact sheet