PhysicianClaim Insight™  is a prepayment fraud, abuse and overpayment prevention service designed to maximize claims payment accuracy, identify fraudulent providers and reduce professional claims costs.  This service combines HCI’s cutting-edge Code Validator Pro™ (rules-based) and Fraud Finder Pro™ (profiling) software systems with claims review by RN Coding Specialists and suspect provider validation by a Clinical Investigative Unit (CIU).

Service Results

• Increase profitability – Average annual payor savings of 2% - 6%
• Reduce PMPM expenditures – Savings from $1 - $5 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

• 100% of professional claims analyzed
• Review by RN coding specialists on all suspect claims
• Code Validator Pro™ software applies rules based on CPT, CPT Assistant, CMS, CCI, commercial products and specialty specific databases
• Overnight claims turnaround with reporting
• Clinically-driven appeals support & response
• Highly customizable rules and parameters
• Easy to use web-based applications
• Fixed and contingency-based fee models

Analytic Features

• Fraud Finder Pro™ software delivers real-time daily 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 providers and claims 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