EMDEON PAYMENT INTEGRITY SERVICES

Transcription

1 EMDEON PAYMENT INTEGRITY SERVICES Emdeon Fraud Prevention Services Emdeon Fraud Investigative Services Emdeon Clinical Integrity for Claims Emdeon Third-Party Liability Analysis Simplifying the Business of Healthcare

2 Emdeon Payment Integrity Services Protection from fraud, abuse and waste Emdeon Fraud Prevention Services Help reduce medical and administrative costs by catching suspicious billing earlier in the claim lifecycle, including pre-adjudication. Emdeon Fraud Investigative Services Help improve cost recovery using advanced technology and in-depth analysis from highly trained investigators with more than 20 years experience. Emdeon Clinical Integrity for Claims Help enhance cost containment through improved claim accuracy and appropriate code corrections using 16 million open-sourced edit rules and Software-as-a-Service (SaaS) technology. Emdeon Third-Party Liability Analysis Help recover overpaid claim dollars and limit future overpayments by leveraging the industry s most comprehensive connectivity to government and commercial payers.

3 Emdeon can help you be confident that when you pay a claim, it s a payment worth making Accurately identify and pay only valid claims while removing fraud, abuse and waste Emdeon Payment Integrity Services help you identify, process and accurately pay only valid healthcare claims efficiently, while reducing healthcare dollars lost to fraud, abuse and waste. This suite offers comprehensive solutions that easily integrate with your existing claims workflow. These solutions can be tailored to meet your immediate needs but also adapt as your organization changes and grows. With its unparalleled repository of claims data, Emdeon has the ability to streamline the information exchange and interpretation, enabling detection of aberrant claims that currently may go unseen, which can result in significant savings for your business. Emdeon s innovative solution set offers the most complete healthcare fraud, abuse and waste solution available today. Our product suite empowers payers of all sizes to intelligently automate processes that previously required a significant investment in human resources and IT infrastructure. When no longer forced to only manage suspect or irregular claims using a retrospective pay-and-chase model, organizations are more productive and efficient. Emdeon can help you be confident that when you pay a claim, it s a payment worth making. At Emdeon, we re here to help. To transform the way you run your healthcare business today, call us at 877.EMDEON.6 ( ) for a complimentary review. 03

4 EMDEON FRAUD PREVENTION SERVICES Emdeon Fraud Prevention helps remove unnecessary costs from healthcare by identifying claim aberrance and catching potentially fraudulent, abusive or wasteful claims early in the claim lifecycle even pre-adjudication. Utilizing advanced technology that includes powerful, data-driven predictive analytics, clinical fraud alerts and more than 16 million clinical code edits, Emdeon can help payers reduce the amount of false positives, minimize costs and improve detection capabilities by automating processes and improving efficiencies. Our combination of technology, experienced investigators and innovative tools offer a complete and unparalleled fraud solution. Flexibility and Innovation Emdeon Fraud Prevention Services integrate seamlessly with existing systems and are available in several models, including: Pre-claim adjudication Post-claim adjudication/pre-claim payment Post-claim payment Enables improved cost containment and overall savings Enhance detection capabilities with automated tools Identify more abnormal patterns within claims data Leverage the power of industry experts Breadth of technology Emdeon uses multiple identification tactics to increase the opportunity and depth of savings. Proprietary database and data mining systems Data-driven predictive analytics Clinical aberrancy rules and alerts Expertise Emdeon s team of fraud analysts, investigators and thought leaders are industry veterans. They include an onsite medical director, registered nurses and certified claim coders. Together, they ve uncovered millions of dollars of fraudulent and abusive claims for their clients. What could they uncover for you?

5 EMDEON FRAUD INVESTIGATIVE SERVICES With Emdeon s Fraud Investigative Services, you can integrate retrospective claims analysis and prospective fraud detection techniques Flexible solution grows with your business Detect fraud schemes quicker Leverage the knowledge and experience of market experts Emdeon s highly flexible, modular offering facilitates an integrated approach to fighting fraud and abuse within a comprehensive Payment Integrity solution. With Emdeon s Fraud Investigative Services, you can combine retrospective claims analysis and prospective fraud detection techniques. Emdeon reviews and analyzes historical claims data, medical records, suspect provider databases and high-risk identification lists while also conducting patient and provider interviews. We offer an outsourced Special Investigation Unit (SIU) that can assist in payment recovery efforts and supplemental investigation methods to augment existing SIU staff. Emdeon s services ensure fair and accurate resolution to problems that develop at any point in the investigation. Experience With more than 20 years experience in healthcare fraud detection, Emdeon s investigators have backgrounds in areas such as law enforcement, criminal justice, private investigation, claims investigation, statistics and analytics. Our onsite medical director, staff clinicians and certified coders further strengthen our investigatory process. We know knowledgeable SIU personnel are often critical to finding and stopping true fraud and our dedication to developing best practices has made us a market leader. Depth of Information and Analysis Because Emdeon works with more than 1,200 payers, we re able to provide clients with an innovative service that enables access to other discovered fraud and abuse schemes within the market. The depth of our data and analysis allows valuable communication among cost containment units interested in relaying information that could result in fewer false positives and more overpayment prevention. Consequently, those who opt for this service may detect schemes quicker and gain additional insight into trends and intentions of potential offenders. At Emdeon, we re here to help. To transform the way you run your healthcare business today, call us at 877.EMDEON.6 ( ) for a complimentary review. 05

6 CLINICAL INTEGRITY FOR CLAIMS Emdeon Clinical Integrity for Claims offers payers flexible and transparent claims edits that leverage more than 16 million rules based on protocols from the American Medical Association, Centers for Medicare and Medicaid Services and other industry sources. Traditionally, clinical edits have been applied after claim processing. However, Emdeon now makes it possible to apply edits prior to adjudication through Clinical Integrity for Claims.* As a result, the number of pended and rejected claims can be reduced, resulting in a smoother, more consistent adjudication and fewer delays in provider reimbursement. Help save time and money with minimal implementation Eliminate clinical integrity infrastructure maintenance Improve transparency and provider relations Transparency and Convenience Traditional proprietary clinical edit solutions can lend themselves to an adversarial relationship with providers. With Clinical Integrity for Claims, edits are transparent and providers receive a consistent message when an error or issue is found. By supporting all editing decisions with tools designed to help providers understand the industry guidance on which rules are based (e.g., the definition of a CPT Code), Clinical Integrity for Claims helps remove the basis of the adversarial paradigm and replaces it with an open and collaborative approach to clinical coding. Comprehensive web tools are offered through a single sign-on portal so payer and provider staffs can view industry edit rationale conveniently. Increased Savings through Pre-Adjudication Positioning One of the keys to reducing lost revenue, increasing profitability and enhancing efficiency is to improve where payers look for billing and coding errors. With Clinical Integrity for Claims, payers can spot common problems like overpayment in real-time while the claim is still in pre-adjudication. The pre-adjudication model can remove much of the work needed by the adjudication system and claims adjusters, and can decrease downstream re-submits and appeals. Payers benefit from industry-leading overpayment protection supported by advanced algorithms, duplicate recognition logic and history-based edits. Together, these components can be configured to work with and improve existing operating procedures. Seamless Integration and Implementation By leveraging a customizable SaaS model and millions of fully sourced edits, Clinical Integrity for Claims delivers savings over and above existing legacy coding solutions that may require significant IT resources or infrastructure. System integration and implementation are quick, easy and seamless so savings and increased profitability can be realized sooner. * Clinical Code Edits powered by Bloodhound

7 EMDEON THIRD-PARTY LIABILITY ANALYSIS Highly cost-effective and results-driven product suite Conduct analysis retroactively for claim recovery or prospectively to maximize cost avoidance Leveraging the industry s most comprehensive payer network and a history of partnering with commercial and government payers, Emdeon Third-Party Liability (TPL) Analysis manages the process of identifying, validating and verifying coordination of benefit opportunities. By recognizing overlaps in coverage, Third-Party Liability Analysis helps recover overpaid claim dollars, redirects payments to responsible parties and limits future overpayments. The Emdeon Advantage Our fully automated solutions provide tools to intelligently manage enrollment and claim processing by seamlessly integrating address, income and third-party benefit verification. Direct integration at these stages of the benefit cycle enables long-term cost avoidance because it improves data quality and consistency. It also allows us to pre-screen members for need, qualification and other coverage, while providing employees an easy-to-use system. Advanced Capabilities Through direct connections and hosted solutions, Emdeon uses member information to discover and verify third party liability, capitalizing on our industry leading payer network and advanced technology. Capabilities include: Smart Scan Analytics that help reduce false positives Online access and file monitoring Real-time transactions to validate TPL leads Batch file processing for TPL discovery Adaptable Solutions By offering customized implementation, Emdeon adapts to each payer s needs and goals. Flexible pricing models Customized reporting and monitoring Daily, monthly, quarterly, bi-annual and event-triggered processing Advanced data exchange platform allows for inclusion of additional data sources Implementing a complete best-practices model makes it possible to identify waste, fraud and inappropriate member benefits before claims are submitted or paid. This proactive approach can help payers avoid less effective and lengthy back-end recoupment practices, which can translate into more efficient healthcare, less expensive benefits and overall savings. At Emdeon, we re here to help. To transform the way you run your healthcare business today, call us at 877.EMDEON.6 ( ) for a complimentary review. 07

8 Discover the Power of an Emdeon Partnership Flexibility. Connectivity. Innovation. Experience. Efficiency. Healthcare payer organizations face unprecedented challenges in many areas, including fraud, abuse and waste. Despite estimates that health insurance fraud and abuse costs many billions of dollars a year, effectively pursuing it adds to operational challenges and expense. However, leveraging emerging business solutions such as Emdeon Payment Integrity Services can offset these expenses by enabling improved efficiency and effectiveness in identifying healthcare fraud, abuse and waste. Emdeon is paving the way for innovative Payment Integrity solutions. To learn more about our company, our services and our commitment to improving healthcare, visit our website at Emdeon Business Services LLC. All rights reserved. EMDA rev Lebanon Pike, Suite 1000 Nashville, TN USA 877.EMDEON.6 ( )