Healthcare

HGS Payment Integrity


360° precision touch at all points of the value chain

Today’s effective payment integrity takes aim at critical impacts like recoupments according to payment risk while also uncovering significant savings opportunities and reducing provider strain. Precise, end-to-end payment integrity has never been more essential to health plan operational costs as well as the quality of the service you deliver to members and providers.

HGS lasers in on payment integrity transformation with custom workflow innovation as well as query and rules design, comprising our precise process, analytics, and industry expertise. Our 1,200 nurses and 400 coders accelerate adjudication, enhance payment integrity, and improve payment accuracy ensuring improved claims operations that will reduce downstream efforts. As a client partner of 5 of the top 10 U.S. healthcare payers, multi-state health systems, and large provider groups, HGS leverages our core strengths in AI, automation, and BPM to improve the traditional PI approach driving greater detection and compliance.

How is our end-to-end Payment Integrity solution precise? We get to the core of key payment challenges, with the right clinical/coding resources and technology, at the right touchpoints, to meticulously identify and resolve triggers causing inaccurate claims.

Our HGS Payment Integrity is uniquely precise. HGS bridges critical gaps to reconcile disparate data and optimize unfocused and limited workflows. We leverage nearly 20 years of payer and claims expertise and deep domain knowledge in the following areas.

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Icon of healthcare ecosystem

The healthcare ecosystem

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The complexities of claims
requirements

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Payer and provider
operations

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Billing processes

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Denials management

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Certified clinical and coding
resources, at scale

HGS’s Precision Payment Integrity has achieved dramatic results for payers through an analytics- and clinical expertise-led cognitive approach spanning pre-pay and post-pay solutions. Our results include annual savings for our clients of $720 million in prepay and $470 million in post-pay.

HGS Payment Integrity touches all points of the value chain…

with a 360-degree approach of end-to-end processes, for exponential return.

Pre-payment

  • Code editing/denial management
  • Prospective overpaymant prevention
  • Datamining and automated reviews
  • Clinical/coding reviews

Post-payment

  • Retrospective overpayment identification
    • Datamining and automated reviews
    • Clinical/coding reviews
  • Retrospective overpayment recovery

SIU Review and Support and Clinical Reviews

  • Intake and assessment (triage)
  • Fact development and documentation
  • Pre-pay rule creation

HGS Payment Integrity areas of core focus

Pre-pay audit process

  • Medical, dental, and pharmacies
  • LOBs: Medicare, Medicaid, commercial, and Tricare
  • Provider specialties handled: DME, surgery, PARE, COB, duplicate, contract groups, IP, anesthesia, SNF, home health

Post-Pay Audit Process

  • Medical, dental
  • LOBs: Medicare, Medicaid, and commercial
  • Provider specialties handled: DME, surgery, PARE, COB, duplicate, contract groups, IP, anesthesia, SNF, home health

Ideation and Research

  • Concept review
  • Missed opportunity
  • Pre-audit analysis
  • Hit-rate analysis/ false positive
  • Post- to pre- reviews
  • Grievance and appeal

Recovery Ops

  • Provider outreach
  • Lockbox support and recon
  • Provider refunds
  • Offset adjustments
  • Cash posting

Annual savings for our clients

$720 Min pre-pay

$470 Min post-pay

HGS Payment Integrity solutions are based on your needs and preferences. We deliver our end-to-end solution via different engagement models: full outsourced managed service model or as an extension to your internal PI team and as a true partner.

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  • Prospective overpayment prevention
    • Datamining and automated reviews
    • Clinical audits – medical record review
    • Coding validation – medical record review
  • Retrospective overpayment identification and recovery
    • Datamining and automated reviews
    • Contract compliance
    • Clinical audits – medical record review
    • Coding validation – medical record review
  • Descriptive and predictive analytics
  • Reporting and insights
  • Discrete PI processes creating value
    • Helping payers insource PI
    • Rules and analytics development
    • Reverse engineering
    • Hit-rate analysis
    • Provider education

Powered by our industry-leading technology and workflow excellence

Audit workflow

Boost internal analyst productivity

  • Analytics library
  • Automated inventory workflow
  • Real-time productivity metrics
  • Expert data science resources

Clinical workflow and analytics

Implement an entire clinical document request strategy from a single platform

  • Analytics library
  • Automated medical records requests
  • Unique tagging of claims
  • Custom workflow and validation
  • Relevant reporting
  • Integrated OCR
  • Digitize clinical content

Pre-pay

Build a solid CMS strategy to “pay it right.”

  • Custom workflows that integrate pre- and post-pay
  • Real-time integration that adhere to stringent SLA performance, maintain common audit and analytic experiences, and streamline disparate data sources
  • Extend post-pay concepts to prepay
  • Inject plan-owned analytics
  • Optimize vendor performance to drive greater pre-pay recoveries, more effectively

HGS Payment Integrity comprises two audit approaches

Datamining

Datamining type of reviews require precise selection of claims using analytics and algorithms to validate the claims are paid as per benefit policies, provider contracts, reimbursement guidelines. These audits are performed by claims analysts and auditors. AI and data analytics play vital role to identify the aberrant claims for review.

Clinical and coding audits

These audit types are classified by provider type and place of service. These require medical records review for the claims selected for audits. The claims are reviewed by licensed nurses, physicians, and certified coders for billing accuracy of the provider based on medical record review. These are more complex audits that require skilled resources.

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