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Please build me a list of Recoupment / Overpayment companies in the Hospital / Insurance (more commonly called 'provider / payer') Revenue Cycle Management space.
Hello! Thanks for your question asking for a list of recoupment and /or overpayment companies in the hospital insurance revenue cycle management space. The best sources I found to answer your question is the article from Becker's Hospital Review.
In short, Change Healthcare, Truven Health Analytics, Discovery Health Partners, Humana, Consova, Conduent, DataMarshall, SCIO Health Analytics, Emdeon Edge and Inniti Alliance are companies that are actively helping insurance companies, employers and providers minimize over payment and reduce wastage. Below see a deep dive of my findings.
METHODOLOGY
I started my research on this topic by carefully studying the links you have provided to understand the kind of businesses you are interested in looking for. Next, I looked for precompiled lists and in my search, I discovered an excellent source of information in Becker's Hospital Review. This guided my research as I read the brief descriptions mentioned in the list and dug deeper to compile information on businesses that closely resemble the ones whose links you have stated in your question. I used corporate websites, industry reports and trusted media sites to put together this research.
COMPANIES
1. Change Healthcare:
Change Healthcare is a Tennessee-headquartered business that provides a whole suite of payment integrity solutions designed to prevent improper payments and fraud, waste and abuse at every stage of the claim lifecycle. They do this by providing analytics and education to improve provider billing practices and provide payment accuracy insight, an integrated repricing network and outsourced audit and recovery services.
In addition, they also offer the following solutions:
-Engagement solutions to improve health outcomes, risk scores, quality ratings, and member retention while decreasing costs of care to both members and health plans
- Payment solutions for consumers and providers including claim settlements, premium payments and consolidated printing that lowers administrative costs and encourages electronic adoption
- Risk adjustment solutions that include data submission, risk model management, risk score trending, risk gap analytics, member and provider targeting, risk adjustment project management, chart retrieval and coding, risk adjustment financials, risk adjustment audits, and provider education.
2. Truven Health Analytics:
Truven Health Analytics is a Michigan-based business that provides payment integrity solutions to insurers among their multiple service offerings. They offer the following solutions under this:
- Enterprise - Health Plans: This includes identification and prevention to investigation and recovery to help businesses fight waste, fraud and abuse
- Advantage Suite - Health Plans: Advantage Suite® integrates information from diverse sources and systems, organizes it to support decision making, and enables easy access to information in a flexible, customized application.
- Consulting Services - Health Plans: Truven provides customized consulting services backed by their data and analytic capabilities.
- Pharmacy Benefit Strategies: This helps businesses control increasing pharmacy costs — without plan design changes or shifting costs.
3. Discovery Health Partners:
Discovery Health Partners is a division of Illinois-based LaunchPoint which delivers solutions, consulting, and analytics that help solve business problems of healthcare clients. They offer payment integrity and population risk management solutions that help health payers improve revenue, avoid costs, and influence member well-being. Discovery’s software solutions are built on their healthcare analytics platform for efficient and flexible delivery that is scalable, secure, and HIPAA-compliant.
4. Humana:
Humana is a large health insurance business that also has a payment integrity unit focusing on ensuring that physicians and other health care providers receive accurate payments for their claims. It was however, not clear to me if they provide these services to their own insurance business or to other insurance companies as well. The unit also works to prevent fraud, waste and abuse.
5. Consova:
Consova is a Colorado-based business that provides payment integrity solutions that cover everything from identification and financial resolution to root cause analysis and prevention. They identify improperly paid claims such as contractual errors, coordination of benefits, duplicate payments, eligibility, improper discounts/allowances, benefits audits and TPL audits. They perform collections in-house and through a mix of partnerships, achieving collections of 75% of every identified dollar within 180 days.
They also perform credit balance audits to identify revenue leakage and recaptured improperly paid funds to payers. Consova maintains SSAE 16 SOC 2 Type II Certification, demonstrating its controls as a service organization relevant to security, availability, processing, integrity, confidentiality and privacy. They work with employers, insurance carriers, healthcare providers, brokers, GPO and private equity.
6. Conduent:
Conduent is a New Jersey-based business that provides an extensive suite of payment recovery solutions, which include subrogation, mass tort, coordination of benefits, accurate CMS reporting, Medicare secondary payer validation, share of cost, pharmacy audits and compliance, medical and pharmacy retroactive termination audits and overpayment identification and recovery.
7. DataMarshall
DataMarshall is a Tennessee-based business that provides payer-payment integrity audit services through a 360 degree approach
- They assist health plans, Insurance Companies, Self-insured employers & TPA's to identify & recover overpayments on claims made to providers
- They conduct retrospective review of paid claims to validate the appropriateness of the billing, coding & reimbursement of the claims
- They perform analysis of the claims to identify potential over payments and provide key insights to the payers preventing future over payments
- They conduct comprehensive sweep on potential overpayments, either as a sole vendor, or as second or third level vendors to complement and supplement the efforts of the existing vendors.
8. SCIO Health Analytics
SCIO Health Analytics is based out of Connecticut and offers payment integrity solutions to help payers, health plans and pharmacy benefits management to control costs associated with third party liability and incorrectly billed or overpaid health claims.
- SCIOMine™ is a browser-based medical and pharmacy claims audit workflow tool designed to cater to customized payment rules and reimbursement methods.
- MY SOCRATES® is a customizable, paperless, subrogation case management software, offering a stand-alone subrogation solution from identification to recovery.
Their services include medical claims auditing and pharmacy claims auditing. They perform all three aspects of auditing: prevention, avoidance and recovery.
9. Emdeon Edge:
Emdeon Edge helps prevent unnecessary costs that drain your profits by identifying invalid claims and catching potentially fraudulent, wasteful or abusive claims up front.
The Emdeon EDGE Fraud, Waste and Abuse Protection Suite uses Software-as-a-Service (SaaS) technology, which allows for flexibility, little to no maintenance, and easy integration with the client's existing claims systems. They also offer Special Investigation Unit (SIU) resources that can assist in payment recovery efforts and supplemental investigation methods to augment existing staff.
10. Inniti Alliance
Inniti Alliance is an Ohio-based business that provides revenue cycle management and fraud detection services. One of their panel experts, Thomas Everett appears to have worked in payment integrity for many years though it is not immediately clear if Inniti offers these solutions.
CONCLUSION
To wrap it up, I found a list of 10 businesses in the recoupment and /or overpayment companies in the hospital insurance revenue cycle management space.
I hope this information. Please let us know if you have any other questions. Thanks for using Wonder!