claim accuracy

increase accuracy, efficiency and cost containment

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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 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.

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.

The results? Individual client results* include:

  • $22 million in savings (5.59 percent) as the primary 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

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

features

  • Audit claims in real-time and batch mode
  • Process claims against entire patient history in sub-seconds
  • Customize rules engine for individual payment requirements
  • Fully transparent open-source edits
  • Efficient and cost-effective SaaS-based architecture
  • Edit library developed and continuously maintained by a team of licensed registered nurses and certified clinical coders
  • A team of clinicians, nurses, and coding experts review claims flagged for policy non-compliance and make payment recommendations within hours
  • Support on provider appeals of coding and/or payment recommendations
  • Reports quantify both ROI and implication of policy implementations

benefits

  • Improve auto-adjudication rates
  • Eliminate maintenance/testing of rule updates
  • Promote payer and provider transparency
  • Increase claims payment accuracy rates
  • Integrate seamlessly with your existing editors
  • Redistribute valuable clinical and IT resources
  • Increase payment and medical policy compliance
  • Contain more improper medical costs missed by other editing systems
  • Redistribute valuable clinical and IT resources
  • Reduce provider abrasion over denied claims

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