Leveraging Subject Matter Experts to Address Payment Discrepancies in a Complex Managed Care Environment
About the Client
A managed care organization serving 400,000 members in a state with complex and unique payment methodologies faced significant challenges in accurately processing healthcare claims.
Due to the intricacies of the state’s payment structure, the organization was inadvertently paying claims incorrectly, leading to both overpayments and underpayments. Addressing these payment discrepancies became a critical priority.
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.
We addressed the problem by leveraging our team of subject matter experts (SMEs), who possess deep knowledge of the state’s complex payment methodologies. The SMEs conducted a thorough audit of the claims process, identifying key areas where payment inaccuracies occurred.
RESULTS
This analysis not only involved the state’s complex payment methodologies, but also included a detailed review of published charge master files. Sagility identified $7 million in overpaid claims for this regional healthcare organization MCO. These results were the combination of Sagility’s data mining capabilities for both professional and facility claim repricing and algorithms.
$7 million
in overpaid claims identified
