It’s not easy making sure claims are paid correctly. Coverage issues, billing errors, third party liability, medical necessity, utilization, adjudication errors, fraud, and abuse all conspire to make the process difficult at best.
With so many opportunities for payment error, a truly effective integrity program must be broad-based and clinically oriented. And it must leverage all information and data available from providers, payors, and other sources.
What Makes Our Approach Different? Unlike other vendors or processes that focus on one targeted aspect of the billing and reimbursement process, such as subrogation or fraud and abuse, HMS provides the entire spectrum of overpayment identification services in a single integrated process. Our approach increases results by 30 to 50%.
Our key differentiator is the exponential benefit that clients receive as a result of our broad perspective in overpayment identification. We look at each episode of care from every angle, and understand how eligibility, coverage, utilization, clinical, and financial information can be used together to profile errors and identify potential overpayments. We share data, insights, and results across our spectrum of program integrity functions, including data mining, clinical review, pharmacy review, subrogation, credit balance review, overpayment disallowance, compliance auditing, and more.
How We Do It. We’re the only company that offers an end-to-end solution that includes data mining, reviews/audits, and recovery, as well as the support for process improvements to prevent future errors. We examine all claim types, including hospital, medical, pharmacy, clinical, long term care, dental, DME, vision, and behavioral health claims.
Clients who use our approach benefit from:
- Increased overpayment recoveries
- Reduced vendor burden
- Reduced provider abrasion
- Increased cost savings through provider education and process improvement
HMS has the experience, resources, and capabilities to perform Program Integrity reviews across the full scope of Medicaid issues and service types. Typically reviews/audits fall into one of four categories:
Financial Reviews
Clinical Reviews
Compliance Audits
SIU/SURS
Regardless of the focus of the review, we employ a wide range of tools to accomplish the objectives, including:
- Data Mining. Our experienced data analysts utilize proprietary analytics, COTS software, and advanced modeling tools to identify overpayments and target providers, claims, and patterns for review/audit.
- Reviews. Our staff of nurses, certified coding professionals, reimbursement specialists, and certified auditors develop and perform structured onsite and desk reviews/audits of targeted providers and claims. Our audits/reviews are supported by sophisticated software, operational process, and quality assurance protocols that help ensure efficient, consistent, and defensible results.
- Recovery. HMS is the only vendor with the infrastructure in place to recover on our findings. We have 25 years of recovery experience.
- Process Improvement. We work to help clients reduce future errors and overpayments through education and process improvements.
