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PRISM Medical Claim Analysis

Claim Overpayment Audit Software

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Claim Overpayment Audit Software


PRISM provides highly sophisticated data mining software that analyzes historical claim payments. PRISM has pre-established queries built into the system and will create additional queries according to client specifications. Analytic results and reports are provided securely to the client on the web. Typically there is an initial historical claims review of 18 months, followed by an ongoing review done monthly or quarterly.

Benefits
  • Retrospectively review 100% of claims without the pressure of making timely payments.
  • Identify members and claimants needing to provide new information about paid claims that was not known at the time of payment (such as other coverage available).
  • Detect recurring claim payment errors and anomalies.
  • Discover incorrectly paid claims that are recoverable from providers and other plans (not members).
  • Perform an ongoing review of enrollment and dependents via software analysis.
  • Fulfill fiduciary responsibility regarding the need for periodic auditing on a continuous basis.

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Claim Overpayment Audit Services
  • Third party recoveries – Coordination Of Benefits (COB), Medicare Primacy, subrogation and other opportunities from legal judgments.
  • Claim overpayments – Includes duplicate payments, claims paid after termination, benefit maximum and exclusions and monitoring for “Never Events”.
  • Provider billing – Provider billing errors and inconsistencies and review against the federal correct coding initiative.
  • Custom analyses – Development of effective queries for any client specified analysis.
Process
  • PRISM receives all claims, enrollment and administrative data from the claim administrator with data field specifications.
  • Data is programmed to utilize for analytical purposes, and validate with data quality reports.
  • Establish analytical criteria with the claim administrator confirming the effectiveness of the queries.
  • Analyze all claims and identify those with recovery potential.
  • Follow up potential claim recoveries until resolution.
  • Provide a complete series of reports on findings.
Contact PRISM Healthcare Resources LLC for a demonstration of capabilities.

Telephone: (586) 468-2138

Email: Info@prismhcr.com
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