Payment integrity solutions enable healthcare plans to optimize processes and maximize returns
by CM Staff
External prepayment processing experts decrease incorrect payments in high-cost inpatient and outpatient facility claims, finds Frost & Sullivan
SANTA CLARA, Calif. — Payment integrity solutions are evolving in terms of technology, strategy, and services for higher claim accuracy. As administrative and clinical claims processes become more complicated, nuanced, and costly to navigate, third-party technologies and expertise are needed. Solution providers can ensure timely payment and records retrieval, lowering the need for specialty clinical claims and coding experts on staff.
Frost & Sullivan’s latest executive brief, A Precision-Oriented Approach to Maximize Savings on High-Cost Claims, examines the value of partnering with an external prepayment processing expert to decrease the instances of incorrect payments in high-cost inpatient and outpatient facility claims.
“By combining the best human capital assets, third-party partners, and technology, health plans can ensure they optimize processes, minimize turnaround times, and maximize returns,” observed Daniel Ruppar, Healthcare & Life Sciences Consulting Director at Frost & Sullivan, in a statement.
Patrick Riley, Healthcare & Life Sciences Principal Analyst at Frost & Sullivan, added: “Health plans are also able to leverage analytics and responsive client support through payment integrity programs to reduce the number of appeals and achieve optimal results, allowing them to focus on core competencies, including critical relationships with members and providers.”
Health plans face myriad challenges related to the capture, management, and collection of revenue from patient services. Over time, the administrative and clinical claims process has become more complicated, nuanced, and costly to navigate, jeopardizing optimal reimbursement and financial return.
“As the leading healthcare pricing and payments company, we offer a comprehensive set of cost management and payment optimization solutions for health plans and providers. As a best practice, we’ve achieved the most success for our clients by targeting and delivering a balance of risk management and financial performance,” noted Jay Deady, President, Claim Cost Solutions at Zelis. “Our comprehensive high-cost bill review is a holistic solution for reviewing expensive inpatient and outpatient facility claims and utilizes itemized bill review, clinical chart review, and diagnosis-related group (DRG) validation of claims pre-payment.”
Zelis’s highly customizable solutions deliver exceptional value, including:
- Utilizing a start-to-finish pre-payment approach to turn high-cost claims around quickly and offer back-end support to minimize conflicts with provider facilities.
- Building customizable solutions to meet health plan turnaround time requirements.
- Supporting records retrieval and fostering long-term relationships with provider facilities.
- Offering a holistic view of medical claim experiences and claim types based on work with clients across the United States.
- Interoperating with most major adjudication platforms so that health plans can seamlessly connect and enhance resource use and operational performance.
- Aligning solutions with those of existing vendors for incremental savings and reduced disruption.