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