Innovative technology designed to help health plans perform through data management and analytics and implement best practices to improve cost containment.
Data mining audits feature the identification of improper claim coding, billing, or payment without the need for medical records review. During data mining audits, Performant applies a library of algorithms to identify claim payments inconsistent with nationally or state-recognized coding standards, violating health plan policies, or containing other clear billing inaccuracies. A data mining finding is triggered when a claim, together with its associated historical claims and other factors, matches the criteria for adjustment.
Performant Healthcare SolutionsSM data mining audits are divided into four groups:
- Provider Billing Errors
- System Limitation/Benefit/Policy Rules
- Contract Compliance
- COB and Eligibility
These groupings include hundreds of edit concepts, such as NCCI edits, unbundling, duplicates, transplant services, MUEs, non-covered services, and multiple procedure reductions.