Incorrectly paid claims reach into the billions annually. As an industry leader in healthcare cost management solutions, West can help you identify, recover and protect your organization from improperly paid claims resulting from overpayments and third party liability situations. We offer no-risk pricing—you only pay us if we recover money for you and you only pay a fee per investigation for our survey services.
Identification and Recovery Services:
We use state-of-the-art data analytics combined with expert knowledge to pinpoint claims payment errors and identify areas of waste. Our highly trained team, with a deep knowledge of health systems processes and reimbursement methodology, works to recover your improperly paid claims. We collaborate with you to implement processes to protect your organization from future incorrect payments.
- Pre-payment overpayment identification
- Overpayment identification and recovery
- Third party liability
Outreach to gather other coverage information or government required group and member information is resource-intensive and can result in fines and penalties if not done properly. Our survey team will do the legwork for you, allowing your organization to focus on accurate claim payments.
- COB discovery
- Employer group size verification—MSP
- Social security number capture
PreVent is the last line of defense against incorrectly paid claims. Designed to supplement auto-adjudication and traditional pre-pay tools, this complete post-adjudication, pre-payment identification and validation solution combines analytics with human interaction to identify areas of incorrect payments before the payments are made to providers.
PreVent uses predictive, data-driven, integrated code edits and clinical aberrancy rules to identify potential mis-payments. We then leverage expert claims processors to validate and correct mis-payments before they are sent. This allows us to look for emerging patterns that help you prevent future issues, increase recoveries and reduce costs immediately.
We recover money for the nation’s largest payers and managed care organizations, amounting to hundreds of millions of dollars a year and a lifetime recovery total of more than $5 billion. Our process employs a proprietary data mining search engine application combined with human analysis that queries thousands of claims in a matter of seconds. We identify improperly paid claims, including overpayments made as a result of missed COB, duplicate payments, eligibility, contractual overpayments, cardiac claims, case rate, DRG and procedure claims and outpatient surgical groupers. Validators manually calculate and verify that the claim is truly overpaid. Claims are then sent to specialists for recovery activity or can be returned to you to perform your own internal recovery effort. You receive regular, detailed reporting of claims recovery status and results. Additionally, you only pay us if we save you money.
West is a leader in the Third Party Liability (TPL) industry. Our proprietary software and expert team analyze claims to identify when other sources for healthcare coverage may be liable for claim payments. Our software uses ICD-9 trauma and E-series codes to identify and accumulate paid claims. Our code library is updated on an annual basis and contains codes that most often represent accidents that result in settlements. Our techniques minimize member abrasion, use your internal resources and can be incorporated into your workflow—from identification through recovery or identification only.
Our Coordination of Benefits (COB) Discovery service eliminates the resource-intensive process of coverage identification from payers, allowing you to focus on correct and timely claim payment. We collect, manage and report other insurance coverage information on your membership population. When identified, transmitted and uploaded into your systems, you can process claims correctly according to the primacy sequence. Additionally, we investigate all past claims in insured patient files to determine if overpayments exist.
Social Security Number Capture
Due to Affordable Care Act (ACA) requirements, payers must now report the SSNs of members who carry the minimal essential coverage. We help by surveying your members to capture the required information. We retain documentation of both outbound surveys and inbound responses at our offices in the event of an IRS audits. This ensures compliance with ACA mandates and allows you to remain focused on your core competencies of timely, accurate claims payments and customer service.
Employer Group Size Verification – MSP
Our Employer Group Size Verification service is designed to help you maintain compliance with Medicare Secondary Payer (MSP) regulations that require you to identify the number of employees in a group health plan to determine whether the plan should pay primary or secondary to Medicare. Incorrect claims payments could result in fines and penalties from the Centers for Medicare and Medicaid (CMS).