UC-427
Claim Edit Tuning and Payment Integrity
Reads paid claim lines against the contract, the fee schedule and the edit library, and ranks which recoveries are worth working.
TBDBuild Duration
XXXXIndicative ROI
XXXXBuild Cost
XXXXValue
The Challenge
Overpayments get found months later by contingency vendors and half the edits that fire are overturned on appeal. Contract terms, fee schedules and edit rules sit apart from the claims they are meant to govern.
How It Works
- Reads paid claim lines, provider contracts, fee schedules, the edit library and appeals.
- Compares each line to contract terms and scores every edit on hit rate and overturn rate.
- Gives payment integrity a ranked recovery worklist and an edit tuning list each release.
What It Removes
- Contingency vendor fees on recoveries found late
- Manual sampling of paid claims for overpayment
- Edits left live long after appeals overturn them
Input Data RequirementsPaid claims and remittance data, provider contracts and fee schedules, clinical edit library and rule versions, appeal outcomes, vendor recovery files
Output FormatRanked recovery worklist with the contract clause cited, edit rule scorecard by hit and overturn rate, prepayment candidate list per release
“We pay a vendor a third of the money to find what our own contract terms said in the first place”