Products & Services: Payment Optimizer® solution

Payment Optimizer® solution is the first fraud, abuse and error detection system for healthcare payers that provides both prepayment scoring and postpayment analysis to reduce fraud losses and ensure payment integrity.

Catch complex fraud and abuse schemes and identify errors before and after the money is paid. 

Payment Optimizer solution is specifically designed to catch complex healthcare fraud and abuse schemes in addition to identifying processing errors, billing issues, internal policy and system flaws.  Government and commercial payers depend on Payment Optimizer to analyze problematic claims activity at various time points before and after payment. 

The early detection, whether prior to or quickly after payment, enables payers to make near real-time decisions.  Payment Optimizer solution helps payers to accurately and efficiently detect which claims should be reviewed prior to payment, then apply historical context to current data to continuously monitor providers for aberrant activity.  By keeping a constant pulse on provider claims activity, payers can take immediate action as soon as a problem occurs.

Payment Optimizer solution also detects fraud, abuse and errors after payment, enabling payers not only to better understand their claims and claims processing environment, but identify cases with potential for high recovery dollar amounts.  By identifying suspicious activity patterns, Payment Optimizer solution enables managers to use this vital information to make fast and accurate business decisions.

How and why it works...

Leveraging advanced science and proven proprietary technologies, Payment Optimizer solution sifts through millions of interactions to piece together a more comprehensive view of the care rendered.  By quickly analyzing medical claims, and patient-related data, you'll have a multi-dimensional picture that accurately identifies suspicious activity.  Fraud risk scores are attached to each claim with easy-to-understand reason codes that take the guesswork out of knowing what to do next. Suspicious cases can be prioritized so you can focus on the riskiest situations and increase the efficiency of your special investigations unit. Payment Optimizer solution can be deployed on-site to integrate with your current IT systems or implemented through our ASP services.

Want More Information?

Visit the Resource Center to access all white papers, customer successes, and all other web-based resources related to this and many other topics.