FacilityClaim Insight™ is a prepayment fraud, abuse and overpayment prevention service designed to maximize claims payment accuracy, identify fraudulent activity and reduce facility claims expenditures.  This service combines HCI’s cutting-edge Code Validator Pro™ (rules-based), Fraud Finder Pro™ (profiling) and claims repricing software systems with review by clinicians, AHIMA-credentialed examiners, fraud specialists and experienced negotiators.

Service Results

• Increase profitability – Reductions of 20%-40% on targeted claims
• Reduce PMPM expenditures - Typical savings range from $1-$4 PMPM
• Greater claims payment accuracy – Impact up to 10% more claims
• Identify fraud with greater efficiency – Eliminate up to 95% of false-positives

Service Features

• Prepayment analysis is on 100% of facility bills
• Review by clinicians/AHIMA-credentialed specialists on all suspect bills
• 24-hour turnaround after medical records receipt
• Highly customizable rules and parameters
• Claims repricing software adjusts claims based on state/payor specific methodology
• Signed settlement agreements obtained to eliminate balance billing (excludes repriced bills)
• Fee negotiation by highly trained professionals
• Fixed and contingency-based fee models

Analytic Features

• Clinical Investigative Unit (CIU) review and validation on all suspect facilities/providers
• Fraud Finder Pro™ software delivers real-time facility/provider scoring and dynamic profiling
• Application of new conditions based on billing trends, fraud scores and clinical validation
• Daily notification to clients of new suspect facilities/providers identified for review
• Identification and verification of federal and state sanctioned providers, deceased providers/patients and Specifically Designated Nationals (SDN)
• Auto-generated statistics, graphs and reports for easy interpretation and assessment