Payment & Revenue Integrity Services
Working with you as a partner instead of as a vendor
As many as one-third of healthcare claims are paid incorrectly each year, contributing to more than $1 trillion in annual waste. Claritev wants to partner with your organization to help identify errors on your claims, improve payment accuracy and prevent you from overpaying.
Uniquely qualified to help you reduce waste and abuse
Unlike other companies that offer healthcare Payment Integrity solutions, Claritev operates networks with more than 1.4 million participating providers. We use our Payment Integrity services on our network claims. We value amicable relationships with providers and work to preserve the relationship between payors and providers.
We value
good relationships
with providers
Tested and proven with
the 1.4 million
participating providers
in our networks
Payment Integrity services applied to our network claims
can easily be applied to yours as well
Experience on the payor and provider side
Several members of our team have worked for payor firms so they understand your goals and the challenges you face. On the other side, we have clinicians and medical coders involved in our Payment Integrity review process who can translate industry codes into clinical situations and determine if a clinical situation is realistic or not.
Blog
What is Payment Integrity?
Improper spending is an enormous problem in healthcare. One tool healthcare payors can use to reduce the overpayments that occur as a result of incorrect, wasteful or abusive billing practices is a payment integrity solution.
What we offer
Pre-Payment Integrity Services
Whether the claim is for a low-dollar doctor’s visit, a costly hospital stay in the tens of thousands or something in between, Claritev has a pre-payment integrity service to identify potential errors.
Advanced Code Editing
Combines automated technology with manual review by clinicians and/or medical coding experts to identify claim lines with improper coding on both network and out-of-network claims.
Clinical
Negotiation
Scores out-of-network claims for improper billing, and then takes claims identified with improper billing through a clinician/coder review followed by a clinically focused negotiation by specially trained negotiators to reach a fair reduction.
Itemized Bill Review
Our systems analyze claims to identify cases, or receive pre-selected cases from the payor, or a combination. We focus on higher dollar claims to identify non-standard and/or more complex billing issues such as duplicate charges or miscoding of services and recommend or negotiate a corrected reimbursement.
Post-Payment Integrity Services
Claritev’s post-payment integrity services maximize recoveries from other responsible parties and help to prevent future overpayments.
Coordination of Benefits
Identify instances of other health insurance coverage to maximize recoveries and drive future cost avoidance
Subrogation
Maximize recoveries from other responsible parties with improved identification and correction to prevent future overpayments
Data Mining
Dig deeper into claims data to identify and resolve incorrectly paid claims, as well as address root-cause issues for future error prevention
Revenue Integrity
Find and restore premium dollars owed to you for managing Medicare Advantage members. We help to manage disease statuses and ensure you receive accurate premium payments from the Centers for Medicare and Medicaid Services.
Medicare Secondary Payer Validation
Verifies whether the health plan member has another insurance that is primary to Medicare
End Stage Renal Disease Validation
Analyzes membership to ensure Medicare Advantage plans are receiving full payments for chronic ESRD members
Our Payment and Revenue Differentiators
Span the entire lifecycle of a claim
From analyzing eligibility to examining claims pre- and post-payment, we’re committed to helping our clients pay network and out-of-network claims correctly.
Combine machine and human intelligence
We leverage technology and human expertise to identify errors on claims so that our clients don’t overpay.
Incorporate four decades of experience
Most vendors have a post-pay-only heritage; our long-tenured focus on the entire claims lifecycle is backed by four decades of pre- and post-pay experience.
Are nimble and flexible
Clients can pick and choose which of our Payment and Revenue Integrity services they want to use and they can use them to complement their existing services or on their own.
Are easy to implement and use
Convenience is a cornerstone of our services. Right from the start, you’ll notice working with us is easy. Implementation is especially simple for payors who already send us files.
