The Challenge

Commercial – Payment Integrity

Claritev analysis uncovered opportunities for a third-party administrator using a variety of PPO networks to:

  • Improve payment accuracy – too much was being missed in the existing editing process
  • Gain control over clinical billing waste and abuse
  • Minimize provider abrasion to preserve leased network relationships

The Solution

Claritev implemented a provider-mindful payment integrity process that balances action with evidence:

  • Claim Correction service to catch errors missed by the primary editor
  • Audit Alert service to enable targeted examination of medical records pre- or post-payment

The Results

Claritev’s Payment Integrity program helps the TPA to deliver greater accuracy and lower medical cost without undue provider pushback:

  • Additional 1% medical cost reduction from claim correction
  • Less than 1% of corrected claims lead to provider appeal
  • Nearly 1% of paid dollars flagged for audit due to more complex errors