Payment Integrity
Comprehensive Approach to Payment Integrity
Changes ignited by healthcare reform have precipitated a new approach to Payment Integrity. Carewise Health uniquely integrates technology, analytics, nurse auditors and case managers to provide a holistic payment integrity solution. Ultimately, our analytics will provide health plans a means to perform “prospective” payment integrity “audits” using the power of the predictive analytics. Our solution spans the point at which we can help a member avoid unnecessary care to the point where the collection of overpayments may be unnecessary. And we’re there every step in between. Health plan customers can now predict and assess risk more accurately and completely to achieve:
More valid and consistent audit results and decisions Improved provider network contracting Improved provider relations Increases accuracy of payments More timely audit results to providers Improved identification of potential fraud and abuse
How we work
To ensure accurate payments and control costs, Carewise Health Payment Integrity addresses every point in the continuum of provider and member activity. Our experienced nurse auditors preserve positive relationships with providers. Here’s how we work:
Use clean and properly assembled claims data sets, and then combine with our proprietary non-traditional data sources to assist in accurately identifying cases requiring field audits Audit targeted cases, using trained, experienced nurses Reconcile payments and recover overpayments when appropriate Identify providers who would benefit from care management provided by our clinicians in order to impact future behavior Identify and resolve patterns to avoid costly errors or fraud in the future
Our platform
The Carewise Payment Integrity Platform is built on four pillars.
1. Data Cleansing, Standardization and Enrichment
Clean data drastically improves analytics and allows for seamless linking of disparate data sets Use proprietary algorithms verify critical content, such as member IDs, provider numbers, diagnosis codes and procedure codes Gain insight from combining traditional and non-traditional data sets
2. QEC (Quality, Efficacy, Cost) Analytics
Use proprietary, predictive algorithms identify the cases that should be subject to nurse audits or care management Create analytics of provider and member profiles Identify and track high-risk providers Build a road map of improved clinical and financial metrics
3. Nurse Field Clinical Audits
Leverage experienced nurse auditors work with providers and recover payments Train Nurses in best-practices, and preserving relationships with network providers 99% success in obtaining signed audits
4. Prevention to reduce “pay and chase”
Analytical insights lead to actions that prevent expenditures and reduce revenue leakage Nurses can engage members through Wellness, Disease and Case Management services in order to influence future behaviors
Data Analytics
At Carewise Health, we offer a range of analytics to drive payment integrity and reduce costs. We use a combination of the most experienced nurse clinicians to carry our Payment Integrity services. They are backed up by data and behavioral scientist, engineers and information technologist to ensure they are using the most reliable and valid data, and the most advanced technology.
Carewise Health supplements our health care domain, clinical and scientific expertise with actuarial and financial expertise to ensure our products and services deliver transparent financial results to customers. Carewise Health has the experience to manage large and complex customers.
Analytics Engine of Payment Integrity
Called QEC (Quality, Efficacy, Cost) Analytics, these proprietary, predictive algorithms can be used to identify and target inappropriate claims and overpayments. Analysis created through the process, generates a road map to improved clinical and financial metrics and analytical insights. This leads to actions that prevent expenditures and reduce revenue leakage.
Carewise Health has access to one of the largest data repositories used in creating unique models and algorithms in support of our products and services. We blend clinical and health care data with non-traditional, non-health care data sets to improve predictability and applications of our models.
Payment Integrity Solution
Identify and recover inappropriate claims and overpayments Identify the cases that should be subject to nurse audits or care management Reduce the cost of the payment cycle Avoid and prevent inappropriate claims and overpayments Experienced nurse auditors work with providers and recover payments for clients Nurses are trained and perform their duties professionally, preserving relationships with network providers 99% success in obtaining signed audits
Audits
Single Source Solution
Our proprietary analytics identify those cases that should be considered for field nurse audits. This proprietary identification and selection process in critical to achieving a higher percentage of successful recoveries, and ensure nurse auditors are investing their time and effort most productively and measurable reduces provider abrasion.
The audit process starts with a thorough understanding of data, claims systems, existing prevention and recovery techniques, and provider networks. We’ll use our team of analytical and clinical professionals to construct the scope of work that bests suits your needs.
Our goal in integrating our service is to find the balance the integration of our services with yours, improve internal knowledge and controls, while respecting contractual obligations with provider networks. We are your recovery team.
Our field staff of clinical professionals handles all issues with records requests, document management and the creation of documents substantiating our findings. The field auditors are part of a team of data scientists, biostatisticians, public health professionals, nurses and physicians that support the important work in the field.