Contract Compliance Reviews

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Leveraging our broad experience in the commercial and government-sponsored healthcare markets, Performant Healthcare Solutions offers health plans regular contract audits that assist in finding breakdowns in billing errors and contract updates that may lead the plan to incorrectly pay more for services than it should:

  • Provider contracts are in a constant state of flux—negotiations, addendums, and updates all rotate on multiple schedules.
  • Language makes it difficult to code all adjudication systems appropriately and timely.
  • Missed billing errors or contract updates can result in the payer incorrectly disbursing more for services than is needed.

Our collaborative, consultative approach mitigates leakage resulting from vague or complex contract language, untimely system updates, manual overrides, “unique” provider relationships”, adjudication system updates, and lack of coordination with contract changes or renewals. Performant’s data mining experts analyze contract language for probability potential of overpayment, and specialists compare contract language to how claims are “firing” within the adjudication system. This team also leverages an extensive library of algorithms to identify individual claims with abnormalities or high probability of contract error to be evaluated against contract language manually, while separate algorithms select groups of claims for basic repricing using logic provided in the contract language that may differ from the original payment amount.