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 to clients 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. This reduces the amount of time that plan investigators spend on false positives by about 65%, leaving more time to investigate true cases and improving provider relationships.
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.
Results? Clients who self-report savings to us, per their process and accounting practices, report savings of between $0.40 and $1.70 PMPM*.
*Based on actual client results. Individual results will vary by client.