Clinical Claim Review

Your pre- and post-pay solution.

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The pre- and post-pay solution to reduce improper claims, improve payment accuracy and minimize pay-and-chase – without member abrasion.

 

With the cost of funding employee health benefit plans rapidly rising, self-insured employers are searching for ways to control increasing expense and risk due to billing errors and payment of improper claims.

To reduce or eliminate these costs effectively, employers want a solution that identifies improper claims before the provider’s payment is issued, rather than the “pay-and-chase” model, where significant administrative costs are incurred.

HMS Clinical Claim Reviews are a proven solution with demonstrated effectiveness. Currently more than 20 million lives benefit from this solution.

Clinical Claim Reviews also make financial sense. Employers can expect a guaranteed 3:1 return on investment, and the benefits are ongoing and sustainable over the long term. Plus, member abrasion is non-existent. The process of reviewing erroneous claims for recovery occurs only between the employer-payer (entity paying the health claims), HMS and the provider. Members are not involved in the process.

Advantages for Brokers and Third-Party Administrators

Clinical Claim Reviews offer similar compelling advantages for a broker of record who can deliver a guaranteed return on investment and other value to self-insured employers.

A third-party administrator (TPA) can pass on significant waste and cost reductions to employer customers as well. TPAs gain a compelling service advantage by implementing Clinical Claim Reviews as part of the administrative services they provide.

How it Works

Clinical Claim Reviews apply proven algorithms to request medical records only for claims that are likely to include improper payments based on analysis against our comprehensive dataset. HMS statisticians update their models daily to ensure continuous improvement. The HMS team of more than 800 clinicians and certified coders review the selected records to find and prevent inappropriate payments.

We currently address these issues in the inpatient environment:

  • Diagnosis Related Group coding errors and clinical validation of codes
  • Covered vs. non-covered services
  • Readmissions
  • High cost drugs
  • Inappropriate short hospital stays
  • Level of care
  • Skilled nursing facility services
  • Inpatient rehab

Pre-pay Reviews

Pre-pay reviews capture savings before claims are paid using advanced analytics – the heart of the Clinical Claim Reviews solution. By applying them to client claims, we accurately identify claims with a high likelihood of error. We then request and review medical records to determine if care was appropriate and coded correctly for billing. The findings from this analysis is reported to the client, along with recommendations regarding proper payment of the claim.

Post-pay Reviews

In the post-pay environment, HMS audit and recovery initiatives use the same advanced algorithms and analyses as our pre-pay solution. Once an overpayment is identified, HMS can optimize the recovery of overpayments and help to correct future improper payments through our industry-leading recovery processes.

The Solution to Choose

HMS’ deep clinical experience and expansive resources allow us to perform high-quality medical reviews that meet regulatory requires and minimize provider abrasion. These reviews are executed within prompt-pay guidelines using tools purpose-built for the task.

Best of all, since our accuracy rate consistently exceeds the Centers for Medicare and Medicaid Services’ requirements, we will protect your bottom line with quality results that help sustain your healthcare program.

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