What is Cost Containment & Care Quality?

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For your state agency and managed care organizations to run at peak efficiency with minimal waste, you need three basic things. Coordination of Benefits, or COB ensures that you only pay claims that you are responsible for. Payment Integrity, also known as Program Integrity (PI), makes sure that Fraud, Waste, and Abuse (FWA) are under tight control, and that claims are medically necessary and correctly submitted. Care quality ensures strategies and services are in place to improve care and reduce costs for members with the highest degree of need.

We pioneered Coordination of Benefits in 1985, when we saw that Medicaid was paying billions of dollars that it shouldn’t. And today, our COB solutions for Medicaid, Medicare, Military and State Agency programs are the best, most innovative available, and we use proprietary data and algorithms that no one else can come close to.

Our PI solutions root out claims that are erroneous for any reason, at any stage in the claim cycle. Payment Analytics, Clinical Claim Reviews, Fraud Solutions, Specialty Audits, Pharmacy and Emerging Solutions. Yep, we’ve got you covered.

Why Cost Containment & Care Quality?

More savings, less stress

Shut down fraudsters

Compliance is built in

How we can help.

We identify incorrect claims before or after payment. If post-payment, we have robust recovery systems in place to get the money back in your account. We can even spot bad claims without medical records from the provider, reducing abrasion and speeding recovery. Machine Learning and Artificial Intelligence are continually making our solutions smarter and more automated, but when a human touch is needed, our people are the best and most experienced in the business. Our advanced care management ecosystem puts personalized, data-driven and actionable care plans at your fingertips, reducing inefficiencies and empowering your teams to focus on what’s important – caring for those who need it most.

Coordination of Benefits

Pre-payment Solutions

Cost avoidance beats pay-and-chase. Our end-to-end COB solutions focus on speed to delivery, and data quality and accuracy to create actionable insights. This, combined with our unique market expertise, ensure maximum cost avoidance for your plan.

Post-payment Recovery

Already paid that claim? No problem. We examine improperly paid claims using artificial intelligence and machine learning to select the best candidates for recovery. Then we pursue those recoveries using efficient electronic processes to maximize savings.

Case Management

Our Case Management solution makes sense of scattered, disorganized data, and drives cases to reimbursement and closure. We deliver secure, reliable, web-based access around the clock, with real-time updates, document imaging and a guided workflow. Our case managers and attorneys are magicians when it comes to complex, high-dollar cases.

Payment Integrity

Clinical Claim Reviews

Our Clinical Claim Reviews identify coding, location, level of service and reimbursement errors by comparing claims against medical records, either pre-pay or post-pay. Driven by synergy between artificial intelligence and clinical experts, our battle-tested and constantly improving algorithms target claims most likely to have errors.

Payment Analytics

Payment Analytics is a customizable post-payment data mining solution. Using exclusive data analysis to compare claims history against specific billing, coding, utilization and reimbursement rules that client systems or claim processors might miss.

Fraud Capture

Fraud Capture is a modular, cloud-hosted platform that provides end-to-end support in the identification of fraud, waste and abuse. Beneficial to operations of all sizes, our intuitive, mobile-friendly software exposes issues through clear data visualization and easy-to-use data exploration tools. Fraudsters can’t hide.

Pharmacy Payment Integrity

Our Pharmacy Payment Integrity solution uses AI-driven analytics to target high-value cases for review. Customization to specific policies and regulations is easy, and clinical reviews are performed by staff pharmacists and nationally certified pharmacy technicians.

Dependent Eligibility Verification

A Dependent Eligibility Verification ensures that you only pay premiums for dependents who are eligible for coverage under plan rules. We handle verifications with compassion and sensitivity, ensuring employees understand why a dependent may be ineligible and explaining the process every step of the way.

Utilization Management

Utilization Management addresses the most pressing needs of state Medicaid programs. Combining cost management with accurate pre- and post-payment claim reviews, utilization management and prior authorization from our Clinical Care Reviews.

Care Management

Our interoperable Care Management platform is built on a solid foundation of automation, standardization and mature processes. Utilizing data from proven, industry-standard COTS products such as the Johns Hopkins ACG System and administrative and clinical information, our service improves quality and reduces the total cost of care.

We can help. But the next move is yours!

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Additional Insights

TRICARE and Medicaid Coordination of Benefits: The System is Broken
Generate Pre-Payment Claim Review Savings by Aligning Payer & Provider Incentives
How Pre-Payment Integrity Can Incentivize Evidence-Based Care