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Payment Integrity ServicesTaking healthcare payment accuracy well beyond traditional editing
Healthcare Payment Integrity Services Overview

Resolve Waste and Abuse Before Payment

Most payment integrity solutions rely on automation of published edits and policies, leaving significant errors – and in particular waste and abuse – on the table. MultiPlan’s Healthcare Payment Integrity services combine automation with expert review. Between analysis and payment we pause to examine, so we can complement existing programs by targeting complex issues like contradictory or overlapping services and suspect billing patterns, that aren’t addressable by computer alone.
Key Benefits
  • Reduces medical spend
  • Improves payment accuracy
  • Complements existing programs
  • Minimizes provider abrasion
  • Evolves with creative billing schemes
  • Delivers intelligence to internal SIU departments
 
Factors + Edits = More Value

Our analysis of hundreds of millions of paid commercial claims from a variety of payers proves that even when sophisticated editing is in place, MultiPlan's payment integrity "factors" find significant additional opportunities for savings through removal of charges billed in error. About 30% of these are National Correct Coding Initiative (NCCI) edits missed by the payers' systems while the vast majority are overpayments from--intentionally or unintentionally--exploited loop holes not easily addressed in standardized coding approaches.

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    How It Works
    Analytical PowerPayment integrity “factors” comprise over 200 million code combinations across 90 service areas – all industry sourced and continuously refined
    • 2.4 million NCCI edits expanded to 115 million
    • 2.2 million industry-sourced rules expanded to 126 million
    • 70% of issues found are complex clinical coding scenarios or suspect billing patterns
    • 100-200 new rules added every month to adapt to new billing schemes
    Clinical PowerAnalytic findings are reviewed by clinicians and coders to ensure their viability and determine a resolution strategy
    • Accelerated process tuned for pre-payment – most reviews completed in only 24 hours
    • Conducted by board certified physicians, certified coders and licensed nurses
    • Enables analytics to go deeper, while minimizing provider abrasion
    Comprehensive OptionsResolution approach can vary based on types of issues found, type and size of claim/bill, and other payer-determined rules
    • Claim/bill correction – pay or deny charges
    • Audit alert for SIU or post-pay action
    • Clinically-focused negotiation, ideal for non-contracted claims/bills
    Physician InvolvementEducation and support for provider inquiries and appeals, including direct access to physicians
    • Easy-to-understand explanations
    • Citations included to help minimize pushback
    • Portal access for payers and providers
Unique Position, Different ApproachOnly MultiPlan brings a cost management heritage to healthcare payment integrity. We know payment integrity, we know providers, and we know pre-payment. Who better to provide solutions that take your historically retroactive process upstream? Contact us