PRISM works in conjunction with a data management partner to analyze historical claim payments. Sophisticated data mining software and queries are utilized to initially review 18 months of paid medical and prescription claims. Thereafter, claims can be reviewed monthly or quarterly.
Benefits
Ø Retrospectively review 100% of claims without the pressure of making timely payments.
Ø Gain new information about paid claims and claimants not known to the claims administrator at the time of payment.
Ø Evaluate the efficacy of the claims administrator.
Ø Identify recurring claim payment errors.
Ø Recover incorrectly paid claims from providers and other plans (not members).
Claim Overpayment Audit Services
There are over 40 categories of claims analyzed for recovery potential in the following modules:
Ø Third party recoveries – Coordination Of Benefits (COB), Medicare Primacy, subrogation and other opportunities from legal judgments.
Ø Claim overpayments – Includes duplicate payments, claims paid after termination, non-covered benefits, missed provider discounts, and others.
Ø Provider billing – Provider billing errors.
Ø Stop loss – Identification of claims that should have been reimbursed by stop loss insurance.
Ø Custom analyses – Development of effective queries for any client specified analyses.
Process
Ø Receive all claims, enrollment and administrative data from the administrator with data field specifications.
Ø Program data to utilize for analytical purposes, and validate with data quality reports.
Ø Establish analytical criteria with claim administrator confirming the effectiveness of queries.
Ø Analyze all claims and identify those with recovery potential.
Ø Follow up potential claim recoveries until resolution.
Ø Provide a complete series of reports on findings.
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