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Payment & Revenue Integrity ĤƵ

Working with you as a partner instead of as a vendor

As many as one-third of healthcare claims are paid incorrectly each year, contributing to more than $1 trillion in annual waste. ĤƵ wants to partner with your organization to help identify errors on your claims, improve payment accuracy and prevent you from overpaying.

Uniquely qualified to help you reduce waste and abuse

Unlike other companies that offer healthcare Payment Integrity solutions, ĤƵ operates networks with more than 1.3 million participating providers. We use our Payment Integrity services on our network claims. We value amicable relationships with providers and work to preserve the relationship between payors and providers.

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We value
good relationships

with providers

operations@3x

Tested and proven with
the 1.3 million
participating providers

in our networks

Data_1@3x

Payment Integrity
services applied to our
network claims

can easily be applied to yours as well

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Experience on the payor and provider side

Several members of our team have worked for payor firms so they understand your goals and the challenges you face. On the other side, we have clinicians and medical coders involved in our Payment Integrity review process who can translate industry codes into clinical situations and determine if a clinical situation is realistic or not.

Blog

What is Payment Integrity?

Improper spending is an enormous problem in healthcare. One tool healthcare payors can use to reduce the overpayments that occur as a result of incorrect, wasteful or abusive billing practices is a payment integrity solution.

What we offer

Pre-Payment Integrity ĤƵ

Whether the claim is for a low-dollar doctor’s visit, a costly hospital stay in the tens of thousands or something in between, ĤƵ has a pre-payment integrity service to identify potential errors.

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Advanced Code Editing

Combines automated technology with manual review by clinicians and/or medical coding experts to identify claim lines with improper coding on both network and out-of-network claims.

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Clinical
Negotiation

Scores out-of-network claims for improper billing, and then takes claims identified with improper billing through a clinician/coder review followed by a clinically focused negotiation by specially trained negotiators to reach a fair reduction.

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Itemized Bill
Review

Our systems analyze claims to identify cases, or receive pre-selected cases from the payor, or a combination. We focus on higher dollar claims to identify non-standard and/or more complex billing issues such as duplicate charges or miscoding of services and recommend or negotiate a corrected reimbursement.

Post-Payment Integrity ĤƵ

ĤƵ’s post-payment integrity services maximize recoveries from other responsible parties and help to prevent future overpayments.

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Coordination of Benefits

Identify instances of other health insurance coverage to maximize recoveries and drive future cost avoidance

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Subrogation

Maximize recoveries from other responsible parties with improved identification and correction to prevent future overpayments

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Data Mining

Dig deeper into claims data to identify and resolve incorrectly paid claims, as well as address root-cause issues for future error prevention

Revenue Integrity

Find and restore premium dollars owed to you for managing Medicare Advantage members. We help to manage disease statuses and ensure you receive accurate premium payments from the Centers for Medicare and Medicaid ĤƵ.

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Medicare Secondary Payer Validation

Verifies whether the health plan member has another insurance that is primary to Medicare

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End Stage Renal Disease Validation

Analyzes membership to ensure Medicare Advantage plans are receiving full payments for chronic ESRD members

Our Payment and Revenue Differentiators

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Span the entire lifecycle of a claim

From analyzing eligibility to examining claims pre- and post-payment, we’re committed to helping our clients pay network and out-of-network claims correctly.

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Combine machine and human intelligence

We leverage technology and human expertise to identify errors on claims so that our clients don’t overpay.

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Incorporate four decades of experience

Most vendors have a post-pay-only heritage; our long-tenured focus on the entire claims lifecycle is backed by four decades of pre- and post-pay experience.

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Are nimble and flexible

Clients can pick and choose which of our Payment and Revenue Integrity services they want to use and they can use them to complement their existing services or on their own.

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Are easy to implement and use

Convenience is a cornerstone of our services. Right from the start, you’ll notice working with us is easy. Implementation is especially simple for payors who already send us files.

A Payment Integrity partner you can count on

“The things we value most about our partnership with ĤƵ is not just the reliable, efficient delivery of savings through their MSP and ESRD services, but the fact that they are always willing to come to the table to discuss and collaborate on new and innovative solutions that nobody else in the industry has yet to try.”
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- Drew Satriano, VP of Payment Integrity at Highmark Inc.
“In our experience, ĤƵ has been very responsive with great turnaround times and the findings they’ve presented to SIHO have been accurate and reasonable.”
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- Claims Department, SIHO Insurance ĤƵ, Inc.
“Partnering with ĤƵ for their MSP and ESRD premium services was one of the easiest PI programs to stand up. The project returned significant value that was being lost due to other Plans changing our members’ status or from being unable to get a member labeled as ESRD. Those factors previously resulted in degradation to our CMS premiums and the project ultimately led to being able to identify gaps in our processes that we were able to shore up.”
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- Drew Satriano, VP of Payment Integrity at Highmark Inc.
“Your team has worked seamlessly with us. I appreciate the professional and courteous customer support everyone on your team renders.”
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– COB Team Leader, regional healthcare plan
“Your team is great at building trust. I have had nothing but a positive and efficient experience.”
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– Manager, large Midwest health plan
“You have been a great partner from Day One. You collaborate with us until we find a resolution. We look forward to a long-standing partnership.”
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– Payment Integrity and Performance Manager, national health plan
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