The healthcare industry is in the midst of a financial crisis, with rising costs and inefficiencies in claims processing bleeding payers dry. According to a 2023 report by the American Medical Association (AMA), nearly 8% of medical claims are denied or overpaid, costing payers billions annually. But the real pain point? High-dollar claims. These complex, high-stakes cases make up less than 2% of total claims volume but account for over 30% of total claims costs, according to the Healthcare Financial Management Association (HFMA).
The problem? Traditional claim review methods—reliant on algorithms or non-clinical staff—are woefully inadequate for tackling these high-dollar, high-complexity cases. Enter ClaimInsight High Dollar Review (HDR) from Advanced Medical Pricing Solutions (AMPS), a physician-led review service that’s flipping the script on how high-dollar claims are handled.
The High Cost of Getting It Wrong
For payers, high-dollar claims are a minefield. Billing errors, overcharges, and unnecessary services are rampant, and traditional review methods simply can’t keep up. Algorithms may lack the clinical context to catch subtle errors, while non-clinical reviewers miss critical nuances in coding and billing. The result? Payers are leaving millions of dollars on the table—and exposing themselves to compliance risks and member dissatisfaction.
Why Physician-Led Review is a Game-Changer
ClaimInsight HDR doesn’t just tweak the process—it reinvents it. By putting licensed physicians and medical directors at the center of the review process, AMPS ensures every claim gets the clinical scrutiny it deserves. Here’s how it works:
- Line-by-Line Itemized Review: Every claim is dissected in detail, with physicians examining each line item for accuracy, medical necessity, and compliance.
- Defensible Decision-Making: Every decision is backed by clinical evidence, reducing disputes and appeals.
- Maximum Savings: By catching overcharges and unnecessary services, ClaimInsight HDR helps payers identify claim accuracy that would otherwise slip through the cracks.
The Limitations of Traditional Review
Let’s face it: algorithms and non-clinical reviewers are great for low-dollar, low-complexity claims. But when it comes to high-dollar cases, they’re out of their depth. Without clinical expertise, they miss the subtle errors and unnecessary services that drive up costs. The result? Payers overpay, compliance risks rise, and trust with members erodes.
A Faster, Smarter Solution
ClaimInsight HDR isn’t just clinically rigorous—it’s built for value and efficiency. Implementation is fast and hassle-free, with the service up and running in days—no complex setup or ongoing maintenance required. Payers can also customize review thresholds to fit their needs, starting as low as $25,000. And with over 95% of findings upheld, payers can trust that every review delivers reliable, defensible results.
The Financial Impact of High-Dollar Claims is Too Big to Ignore
The bottom line for payers - overpayments, compliance risks, and inefficiencies are eroding margins and undermining trust. ClaimInsight HDR offers a proven solution: a physician-led review process that combines clinical expertise with operational efficiency to deliver unmatched accuracy and savings.
As the healthcare landscape continues to evolve, payers need innovative solutions that address the complexities of today’s claims environment. With ClaimInsight HDR, AMPS is leading the charge, empowering payers to take control of high-dollar claims and achieve better financial and clinical outcomes.