Pre-Payment Clinical Review
Improving payment accuracy before payment is made with automation and expert clinical review
Identify waste and abuse before payment is made
Most payment integrity solutions rely on automation of published edits and policies, leaving significant errors behind.
Our Pre-Payment Clinical Review ±«ÏÊÄ¤ÊÓÆµ combine automation with expert clinical review. Between analysis and payment, we add a level of human clinical expertise to examine claims where appropriate. This complements ±«ÏÊÄ¤ÊÓÆµâ€™s robust analytical programs by targeting complex issues such as contradictory or overlapping services and suspect billing patterns that are generally not addressed by computer alone.
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Ways we help with pre-payment savings
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.
This service scores out-of-network claims for improper billing, and then takes identified claims through a clinician/coder review followed by a clinically-focused negotiation by specially-trained negotiators to reach a fair reduction.
Advanced Code Editing
Our automated technology combined with manual review by clinicians and/or medical coding experts, identifies and flags claim lines with improper coding on both in-network and out-of-network claims. Flagged charges are recommended for denial, and then education and support is provided after payment as needed to address provider questions.
Over forty years of Pre-Payment Clinical Review experience
We're clinically focused
We involve clinicians at every step, including daily claim reviews and provider appeal support.
We go beyond automation
We integrate clinical review to confirm complex issues prior to recommendation.
We know pre-payment
Four decades of pre-pay experience - most claims returned within 24 hours.
We know providers
We contract with over 1.2 million practitioners and facilities; with an appeal rate of 3%, we minimize provider abrasion.
We know waste/abuse
With our long-tenured focus on non-contracted claims, we see the most creative billing schemes.
We're a trusted partner
We are HITRUST certified with nearly 300 payors depending on us for pre-payment integrity services.
Our Pre-Payment Clinical Review services blend human processes with technology, finding issues standard editing software canâ€™t â€” and resolves them before payment is made.
Your Clinical Review partner
Better payment accuracy means more affordable healthcare and a stronger provider-plan-patient relationship.
Minimize future billing errors with explanations and education that improves the quality of provider billing
Detect and correct complex billing errors and suspect patterns normally only addressable in a post-payment review
Focus recovery efforts for more egregious overpayments by lessening the number of incorrect billing scenarios that make it through your pre-payment adjudication