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.
Retrospectively review 100% of claims without the pressure of making
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
Detect recurring claim payment errors and anomalies.
Discover incorrectly paid claims that are recoverable from providers and other plans (not
Perform an ongoing review of enrollment and dependents via software
Fulfill fiduciary responsibility regarding the need for periodic
auditing on a continuous basis.
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
Provider billing – Provider billing errors and inconsistencies and
review against the federal correct coding initiative.
Custom analyses – Development of effective queries for any client
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