Top 5 Ways Smaller Health Plans Can Realize Big Savings

In today’s increasingly complex healthcare landscape, small to medium-sized health plans may lack the scope and depth of clinical resources to fully establish a proven payment integrity solution. As such, they can be defenseless against the myriad of outside forces determined to overstate claims, costing them millions of dollars on an annual basis.

MedReview’s payment integrity solutions, which include DRG Coding Reviews and Clinical Validation, as well as Hospital Billing Audits and Data Mining, provide small- to medium-sized health plans with an opportunity to immediately shore up their defenses against suspicious claims and save millions without the capital expenditure associated with building out these capabilities internally.

MedReview’s unique combination of clinical expertise and AI-driven technology can identify errors and coding schemes with remarkable speed and accuracy – before they affect your bottom line. And because every reassignment is reviewed and approved by one of our board-certified physicians, our reassignments are highly defensible with an appeal overturn rate of less than 5%. Here are five ways MedReview is helping small- to medium-sized health plans take their payment integrity efforts to the next level:

1. Clinical Validation to Maximize Savings

Coding reviews only touch the surface of a clinical chart review. While coding errors are commonplace, they do not offer the greatest opportunity for identifying overpayments. DRG clinical validation, however, provides the holistic chart analyses needed to maximize savings. This is where skilled physicians review the medical record with the claim to determine if the DRG submitted aligns to the clinical diagnosis as documented. The clinical review at MedReview is an intensive audit performed by board certified physicians with specialty experience that is appropriate for each case.

MedReview employs board certified physicians in every clinical specialty who review and approve every claim reassignment. With highly trained physicians who have significant clinical validation experience, most inaccuracies are identified and resolved resulting in significant payor savings.

MedReview appreciates the valuable relationships that small- to medium-sized health plans have with their providers. Local providers play an important and influential role in the communities they serve as they are relied upon by the local populace and area visitors to deliver high quality medical care that has been tailored to meet the specific healthcare needs of the local community. As such, we take very seriously our responsibility of ensuring these providers are fairly compensated for the clinically appropriate and properly documented care they deliver. When a board-certified MedReview physician reassigns a DRG during the review process, health plans typically feel very confident in the results. In fact, 95% of MedReview reassignments are upheld.

2. Immediate Information Technology Upgrade

One of the most serious challenges faced by smaller health plans is a lack of advanced analytical capabilities supported by artificial intelligence.

While change management can be a difficult process, digital transformation is essential to ensure the survival of small- to medium-sized health insurance providers. With ever-changing regulations, an increased emphasis on quality and cost savings, and the transition to value-based contracts, health plans should only be paying for the care that was delivered.

MedReview’s robust information technology infrastructure features advanced workflows and proprietary machine learning algorithms that have been enriched by decades of real-world clinical data. This enables smaller health plans to maximize the return on their payment integrity investments – without having to invest the significant capital required to build out these advanced capabilities internally.

At MedReview, our analysts, coders, and physicians use advanced AI-driven information technology to identify and resolve suspicious claims with remarkable speed and accuracy. With the availability of real data transparency, payers and providers can enter value-based contracts on equal footing.

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3. A Deep Understanding of Current Coding Guidelines

DRG coding guidelines are constantly updated, requiring continuous monitoring to understand when new guidelines are being implemented and when they go into effect. Without the latest and greatest updates from the Center for Medicare and Medicaid Services and other regulatory bodies, payers may lack the information required to provide actionable and educated oversight on their claims and be unable to guarantee claims are being paid appropriately. MedReview employs a vast team of highly trained coding experts, nurses, researchers, analysts, and board-certified physicians who are dedicated to dotting every “I” and crossing every “T” to ensure compliance with latest regulatory requirements. We also bring a superior level of clinical expertise regarding the conditions most susceptible to upcoding schemes.

4. Advanced Algorithms Enriched by Decades Worth of Clinical Data

Actual clinical data is the fuel that enables healthcare algorithms to drive machine learning. The more real-world clinical data you put in, the more accurate and actionable the data becomes once it has been normalized and enriched. As a result, a relatively new algorithm launched by a start-up, for instance, will not deliver near the insights provided by a mature algorithm that has been learning for years. Real, high-quality clinical data cannot be bought, either, which precludes many start-ups from being able to buy their way into the market. Rather, quality clinical data is an asset to be cultivated, curated, normalized, and enriched before it results in usable insights to decision makers. Fortunately, MedReview has been building out its technical and analytical resources for nearly 50 years, giving it one of the most robust clinical databases in the country. As a result, MedReview delivers industry leading payment integrity that can save your organization millions.

5. Comprehensive Protection Against Fraud and Abuse

As much as we would all like to believe that serious abuses are not taking place, some providers continue to play fast and loose with the coding guidelines to increase their revenues. Each week, the industry trades are filled with headlines about health systems and physicians being charged or pleading guilty to all manner of upcoding schemes and other illegal billing practices. Without a mature payment integrity platform designed to flag claims inaccuracies and protect the bottom line, smaller health plans risk losing millions to improper billing practices.

MedReview’s payment integrity platform is designed to immediately identify and resolve suspicious claims with the highest potential for fraud, waste, and abuse. As a result, we’ve saved our payor clients more than $3 billion, including $351 million in savings just last year.

To stop unscrupulous billing practices and start saving your health plans millions, contact MedReview today.