System Limitation, Benefits & Policy Rules

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Data mining is not just automation and claims edits. Performant Healthcare Solutions realizes the logic of each scenario needs a keen, trained eye to ensure appropriate actions are taken to address system limitations, benefits, and policy rules and to safeguard the health plan’s provider network from unnecessary abrasion.

Data mining for system limitations addresses the difficulty claims adjudication and editing platforms have in identifying complex scenarios that span multiple claims, providers, and patients. Performant’s proprietary algorithms can identify these scenarios that might be missed by internal or outsourced editing software.

Data mining for benefits offers a responsible, balanced approach to identifying thousands of claims to reach maximized savings using a combination of manual intervention and advanced data mining technology.

Data mining for policy combines expertise of Performant’s Legal and Compliance teams, as well as our Business Development and Innovation teams, to stay abreast of industry trends, standards, and regulatory changes. If we notice an industry policy not being implemented or fully leveraged, we notify our clients and offer potential updates to their policies that will match the industry leaders, as well as reveal additional opportunities for savings in medical spend.