The Risk Prevention Services offering focuses on reducing costs related to specific billing issues by identifying providers with aberrant billing patterns (as compared with internal and external benchmarks). Once aberrant providers are identified, we provide the plan with a list of these providers and summary billing statistics. We also deliver educational materials designed to correct billings and resolve identified overpayments.

How it Works: Our detection software compares provider billings with internal and external benchmarks. Outlying providers receive analytical results as well as educational and audit reference materials (compliance guidebooks) to assist them in self-review and resolution. These providers are instructed to return any overpayments identified through self-review, and may also be subject to prospective and retrospective investigations. Follow-up analysis is performed regularly to confirm that aberrant billing practices have been corrected and to quantify the impact of the program.

Benefits

• Identifies providers whose billing practices depart from benchmarks
• Engages providers in self-review, which helps prevent overpayments. (Plans have seen a 22-percent reduction in claim costs addressed by Risk Prevention.)
• Helps plans collect overpayments made to providers

Information

For more detailed information, please call 1-800-569-1222 or click on the link below. Request more information     Contact a sales rep