The Role of Payment Integrity Amidst Rising Medical Costs
About the Client
A national health plan faced increasing medical expense costs while needing to maintain margins in an environment where CMS and state Medicaid agencies independently set the annual revenue trends.
Looking for a way to help manage their medical expenses, the national health plan focused on payment integrity to ensure it was paying claims according to contractual terms.
Using our proprietary Intelligent Content Processing software, Contract Central, Sagility began auditing contract agreements against financial transactions to ensure compliance with contractually agreed-upon rates.
RESULTS
Through a detailed analysis of claims data and contract reviews, auditors successfully identified financial errors and discrepancies in claim payments, resulting in the detection of $28 million in overpayments during the first year.
This analysis involved a detailed review of all relevant claims, comparing them against contractual agreements and payment terms. The findings highlighted errors in the health plan’s initial calculations, prompting a reassessment of the financial reconciliation between the health plan and the healthcare facility, ultimately providing a more accurate picture of the financial situation.
During our first year, the national health plan radically transformed its payment integrity infrastructure. Despite these significant changes, Sagility remained adaptable and collaborated closely with the health plan to adjust processes, ensuring seamless integration and continued success in optimizing payment accuracy and efficiency. This flexibility allowed us to effectively support the plan’s evolving needs while maintaining a high level of operational performance.
To date, we have identified more than $148 million in overpaid claims for this national health plan, which serves Medicaid and Medicare beneficiaries.
$28 million
in overpayments during the first year
$148 million
in overpaid claims identified
