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Pre-pay Clinical Claim Review

Here’s Innovation That Pays.

Post-adjudication Clinical

When state Medicaid agencies identify improper claims before paying them, you not only save the cost of the claims themselves, but also avoid the time, effort, and expense involved in recovering incorrectly paid claims.

HMS offers states pre-pay Clinical Claim Review to identify improper payments before a claim is paid to improve your program integrity efforts. By performing claim reviews this way, you can avoid payment errors related to Diagnosis Related Group coding and validation, readmissions, level of care, place of service, and more. We can screen all of your claims for issues and review those that are selected.

Our solution:

  • Reduces the administrative burden associated with pay and chase
  • Increases provider cooperation and results in fewer appeals
  • Increases potential savings over traditional post-payment approaches
  • Delivers expedited savings

We use time-tested algorithms – built and refined over many years – to target claims with the highest potential for findings. We request medical records only when there’s a likely improper payment. Our expert review staff includes more than 800 clinicians and certified coders – all under the direction of our Chief Medical Officer.

HMS’s experience allows us to perform high-quality reviews within prompt-pay guidelines. Our accuracy rate consistently exceeds the Centers for Medicare and Medicaid Services requirements.

A recent HMS pre-pay Clinical Claim Review on 500,000 Medicare members produced the following results:

  • Over $20 million in projected savings in nine months
  • Savings recognized within 20 days of the receipt of the first medical record
  • Initial selections provided within 45 minutes of claim receipt
  • Decrease of rebuttals by more than 50% compared to retrospective clinical reviews
  • 67% reduction in overall provider call volume (versus post-pay)

Innovations like these demonstrate HMS’s commitment to continuing to provide the broadest range of cost containment solutions in healthcare for you.

Incorporate the newest technology into your program integrity work with HMS pre-pay Clinical Claim Review.