Protecting Your Health Plan: How Claim Pattern Review Delivers Results
Are you looking for ways to strengthen payment integrity and reduce improper claims? Maintaining a robust system for identifying and preventing fraudulent or erroneous payments is crucial for any health plan. Highmark Wholecare discovered a powerful solution – Claim Pattern Review – and the results speak for themselves.
The Highmark Wholecare story
Highmark Wholecare successfully implemented Claim pattern Review, leading to significant improvements in their payment accuracy. They were able to proactively identify and prevent improper claim payments, safeguarding valuable resources. This experience highlights the tangible benefits this approach can offer your organization.
What is claim Pattern Review?
Claim Pattern Review is a proactive approach to identifying potentially problematic claims before they are paid. It goes beyond customary fraud detection methods by analyzing claim data for unusual patterns and anomalies. This allows you to address issues early, minimizing financial losses and protecting your plan’s integrity.
Benefits for Your Health Plan
Here’s how Claim pattern Review can benefit your organization:
Rapid Return on Investment: Automated detection capabilities allow for quick identification of suspect claims, all while adhering to prompt-pay regulations.
Significant Savings: you can potentially realize savings of up to 0.30% of your annual professional claim spend.
Early Fraud Detection: Identifying potential fraud cases sooner allows for faster intervention and improved payment accuracy. Increased Staff Efficiency: Empower your Special Investigation Unit (SIU) staff to focus on high-priority cases without needing to overhaul existing systems or resources.
How Claim Pattern Review Works
This isn’t about adding more work to your team’s plate. It’s about working smarter. Claim pattern Review leverages advanced analytics to:
- Analyze Claim Data: The system examines vast amounts of claim data, looking for deviations from established norms.
- Identify Suspicious Patterns: Unusual billing practices, outlier claims, and other anomalies are flagged for review.
- Prioritize Investigations: Your SIU team can then focus their efforts on the most promising leads, maximizing their impact.
- Prevent Future Losses: By addressing the root causes of improper payments, you can prevent similar issues from occurring in the future.
Ready to Explore the Possibilities?
I’ve found that a proactive approach to payment integrity is always the most effective. Don’t leave money on the table – or worse,unknowingly fund fraudulent activity.
Read the fact Sheet to learn more about how Claim Pattern Review can help your health plan achieve lasting results. Here’s what works best: understanding the potential impact on your specific plan and taking the first step towards a more secure future.
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