Decrease Improper Payments with an End to End Risk Mitigation Program

Sponsored Content -- By James McCall, AHFI, Director, Fraud Analytics, Emdeon

Tackling Fraud, Waste and Abuse can be a daunting task for payers. It typically requires significant resources, access to sophisticated data and high levels of expertise. Even then, the return can be marginal and disruptive to provider relationships.

An effective risk mitigation program takes an end to end look at healthcare cost containment. This type of approach takes advantage of savings opportunities at every stage of the claim lifecycle. This includes cost avoidance in a stage often overlooked: pre-submission.

A 3Dimensional Approach Can Increase Savings
A comprehensive end to end process can help develop an effective risk mitigation program with distinct actions: Avoid errant disbursements pre-payment; Prevent inappropriate payments; Detect high risk behaviors post payment; Inspect and Audit rendered services. These actions take place within three dimensions of the claim lifecycle:

  • Pre-submission: by addressing aberrant billing practices, future claims are correctly coded before submission, allowing payers to avoid unnecessary costs

  • Pre-payment: by closely monitoring and identifying aberrant claims through code edits, the application of investigative rules and multi-payer analytics, and early detection of anomalies, payers can detect outliers and combat costs prior to issuing payment

  • Post payment: when claims are incorrectly paid, clinical reviews, additional analysis and investigation help recoup dollars lost to improper payments.

Pre-submission: A New Approach
Taking a closer look at savings opportunities in the Pre-submission stage of a claim can, at first, seem unusual and possibly even ineffective. Emdeon has proven otherwise. With Emdeon Coding Advisor, a solution that combines MultiPayer analytics, a sequenced process benchmarking provider billing and education, Emdeon is helping payers avoid improper claims--before they are submitted to the payer. 

The Savings Are Real
After reviewing Evaluation and Management (E/M) claims for a large payer over the course of a year, results were significant. The payer ultimately realized $27M in savings, derived from costs avoided as a result of more accurate billing for E/M services. These were "hard" savings for the payer, as a true reduction in the cost of care was achieved and quantified by the payer. After four quarters of demonstrated success, Emdeon added code sets to the program and continues to see similar rates of savings for the expanded code sets.

Learn More at NHCAA ATC 2014
To learn more about avoiding costs with a Pre-submission solution, join us at NHCAA ATC, Wednesday, November 19th, 9:00-10:15 a.m. James McCall, AHFI, Director, Fraud Analytics and Dave Cardelle, R.Ph., Vice President, Operations, Payment Integrity, Emdeon, will be discussing End to End Risk Mitigation of Improper Payments. Or visit for more information.

Emdeon has built one of the most complete suites of payment integrity services, Emdeon EDGETM. Consider a partner who has the edge of today's best practices for payment integrity and claims cost management. For more information on avoiding unnecessary cost, go to