Services
Whether it is driving incremental recoveries in an existing audit area or developing new areas, Connolly knows where to look to find improper payments. Download our Healthcare Service Overview here.
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Review provider compliance with contract terms and conditions that could include areas such as: capitated services paid as service fees, retroactive rate reductions, incorrect level of care paid, and missed or inappropriate provider discounts. Identification and recovery for other party liability, including other commercial insurance, Medicare, or Medicaid, or other state-sponsored plans. Certain overpayments require a more in depth review of clinical documentation to uncover. Medical Chart Review is a recommended part of a comprehensive audit program to identify overpayments in medical necessity, DRG, and many other claim adjudication review areas. Identification and recovery of duplicate medical claim payments, multiple providers, interim billing and split bills. Medical Benefit - Escalating drug cost and utilization, coupled with often complicated billing and adjudication processes, creates challenging payment dynamics. A review of pharmacy claims adjudicated under the medical benefit will identify payment errors, prevent future overpayments and help establish predictable cost projections.
PBM - When you outsource pharmacy benefit claims to a PBM, how do you ensure the claims are adjudicated according to your contractual terms, formularies and benefit designs? A post-payment review of the pharmacy benefit will recover past overpayments and allow for system corrections to prevent errors moving forward.
This encompasses reviewing provider billing in conjunction with payer contracts and payment guidelines to ensure proper payment. Areas may include: procedures, transplants/implants, CPT coding & modifiers, ambulance related services, anesthesia, observation, and DRG Determining if claims submitted are for terminated plan members such as terminated groups and individuals, or state disenrollment Your members are winning lawsuits related to faulty implants and the damaging effects of certain prescribed drugs. As a result, cost responsibility for the incurred treatments has shifted from the health plan to the manufacturers. These situations are most often not covered in your subrogation audit scope of work – subrogation audit vendors are typically focused on accident related codes – not potential product recalls.
We can identify members who may be taking legal action, and will coordinate with you for the best outreach methods to confirm what decisions have been rendered. In many cases we already have established relationships with the manufacturer and their third party claims processors – helping deliver results as quickly and seamlessly as possible. |
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Download the white paper:
Improve Detection of Abusive Billing at No Additional Cost
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Download the white paper:
Reducing Specialty Drug Expense through Identification and Elimination of Claim Payment Errors
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