High Risk & Specialty Audits

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Labs, genetic testing, high-cost drugs and outlier claims represent a significant category of spend for health plans and are the source of costly, improper payments. Adopting a comprehensive and ongoing review of these high risk and specialty claims not only improves health plan oversight of claims payment accuracy, but also reduces fraud, waste, and abuse.

Performant Healthcare Solutions utilizes sophisticated scoring and selection algorithms to identify claims for audit that offer the highest probability of recovery and focus on validation of the clinical, contractual, and financial components of a claim.

High-cost drug audits review claims administered via home infusion, in physical offices, and in outpatient hospital settings to help improve plan oversight of high-cost injectable and specialty pharmaceuticals.

Clinical lab and genetic testing audits, often delivered in conjunction with Performant’s broader outpatient audit program, identify lab testing that is miscoded, duplicative, inappropriate, and contrary to payer policy.

Outlier claims audits, review claims in both the inpatient and outpatient place of service. This line by line bill review includes a comprehensive assessment of coding, clinical validation, unit validation, service level validation and pricing validation of high cost implants, drugs and ancillary charges that push claims over typical thresholds.