Annually process millions of claims resulting in billions in benefit payments.
Using a multi-point claims monitoring approach and state-of-the-art tools, we offer extensive subject matter expertise in claims workflow and adjudication. Each year, we process millions of claims resulting in billions of dollars in benefit payments with efficiency and effective controls.
Education & Outreach
Annually deliver hundreds of virtual and face-to-face events reaching over 10K participants while maintaining customer satisfaction scores of 4.8 out of 5. We offer more than 100 self-paced courses that have more than 25K views.
We have a nationally-recognized education and training team that partners with our providers to ensure they are prepared to effectively serve the beneficiaries of government programs. We deliver virtual events reaching thousands of participating providers while maintaining high customer satisfaction scores. Using a variety of methods, including creative and high-tech curricula design, our team is able to reach our large, diverse health care provider population, resulting in well-informed providers.
Using data analysis to target reviews, we process millions of automated and complex reviews and conduct outreach efforts to ensure billing and documentation compliance.
With our credentialed staff, Certified Professional Coders (CPCs) and PhD and master’s degree-level statisticians we provide training, experience and technology to our providers to ensure provider compliance with federally mandated rules and timeframes. Using our unparalleled expertise, we offer our business partners the tools they need to make data driven decisions to identify aberrant and/or emerging billing patterns. The creation of self-service reporting tools further allows our business partners to access valuable and near-time information, resulting in annualized resource hour savings.
Annually control, index, and distribute millions of incoming hard copy and electronic documents or pages using image capture technology and optical character recognition (OCR).
With our state-of-the-art hardware and software, we are able to streamline the processing of millions of paper documents providing input into automated workflow management systems. Our expertise in mailroom and document management systems and processing has resulted in an annual control, index, and distribution of millions of incoming hard copies and electronic documents and millions of pages using image capture technology and optical character recognition.
Enrollment & Eligibility
Annually process nearly 100 K provider enrollment transactions.
Our provider enrollment experts offer enrollment systems and processes to establish new providers, manage changes to enrollment records and perform critical information validation. Scalable resource models offer solutions for unexpected or increased workloads and our proven fraud-prevention approach minimizes burden for qualified providers while monitoring for fraud schemes to quickly identify non-compliant activities post enrollment.
Annually process close to 1 million provider inquiries, approximately 5 million portal inquiries and thousands of beneficiary inquiries.
Our customer service team uses the latest in call center technology to forecast call volumes and resource needs, monitor and track service levels and monitor the quality of responses to customers. Our proprietary Customer Relationship Management (CRM) tool aggregates all customer information to provide a holistic view of the customer’s transaction history.
In its infancy, we helped CMS start up and expand the Prior Authorization program.
We are here to help safeguard beneficiary access to medically necessary items and services while reducing improper Medicare billing and payment.
Perform financial management, reporting and reconciliations for government payments and debt management activities.
We are experts in managing large, complex financial operations and reporting. The benefit accounting team brings extensive experience as the recognized subject matter experts in the implementation, ongoing operations and continual enhancement of financial systems. Our established strong control environment has resulted in the recovery of debt for government programs and recent identification of a provider enrollment fraud scheme.
Audit & Reimbursement
Process thousands of cost reports and perform audits / reviews including complex reviews of Medical Education, Organ Acquisition, and Charity Care.
Our audit and reimbursement team is comprised of experienced, credentialed staff who are experts in interpreting and applying agency laws, regulations and agency guidelines. With our comprehensive risk-based processes, we can identify providers that may have issues that could result in significant dollars being at risk for audit through automated tools and technologies. A secure, paperless workflow environment provides innovative and effective management control, ensures consistency, timeliness and quality of work product.
Annually process more than 1 million appeals.
Processing more than a million appeals, our team is here to help you. With tools and technologies, we are able to efficiently and effectively deliver timely, high quality appeal decisions. Our registered nurses help enhance the appeal decision quality by providing a broader experience in complex clinical procedures and patient care.