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Innovative Accuracy Solutions

Performant’s healthcare division offers broad experience in the commercial and government-sponsored healthcare markets. Our experience features the provision of payment integrity services to some of the nation’s largest, national commercial payers, as well as to a host of regional payers and Blue Cross Blue Shield plans.

In 2016, Performant was re-awarded CMS Recovery Audit Region 1 (formerly Region A) and also awarded the newly created Region 5 as the sole national auditor for DMEPOS, Home Health and Hospice claims nationwide. Under these contracts, Performant identifies and prevents improper payments through the deployment of advanced data mining technology, automated and complex clinical reviews, coupled with robust provider outreach efforts. To date, Performant has facilitated the return of over $2B to the Medicare Trust Fund.

In 2017, Performant was awarded the CMS Medicare Secondary Payer Commercial Repayment Center (MSPCRC) contract by CMS. With this award, Performant serves as the sole national vendor responsible for the identification and recovery of payments where Medicare should not have been the primary payer.

MSP Advantage

A comprehensive solution suite for premium enhancement—led by eligibility experts, backed by sophisticated analytics.

The Problem

  • An estimated 4% of Medicare enrollees (2.4 million) have other primary health insurance coverage
  • Member premium payments are dependent upon an accurate accounting of members with other insurance
  • Untimely, inaccurate information leads to underpaid premiums, missed cost avoidance, and post-payment recoveries
  • Complicated, lengthy procedures to modify CMS premium information demands dedicated plan resources and expertise to maximize bottom line impact

The Solution

  • Leverage an extensive database and proprietary algorithms to identify and validate other coverage information and accelerate premium revenue and/or MSP program savings
  • Deploy a highly trained team of outreach professionals for manual validation of low-quality data matches and to coordinate with the MA plan, CMS, and other coverage providers
  • Validate primacy to increase recovery of overpayments by $4 to $7 per member per year (PMPY)

The Suite

As the vendor of choice for Medicare and Medicaid plans and the national CMS Medicare Secondary Payer (MSP) Commercial Repayment Center (CRC) vendor, Performant capitalizes on our expertise and established relationships with commercial and government payers, as well as healthcare providers, to provide proven, purpose-built cost containment solutions backed by transparent reporting, proprietary analytic tools, and a team of specialized industry professionals. Our MSP Advantage solution suite includes:

  • Payment Accuracy—identify opportunities for premium restoration utilizing sophisticated analytics, multiple sources of eligibility data, and a deep bench of analysts and outreach professionals. The payment accuracy Advantage—reduce frustration with deteriorating premium dollars by restoring underpaid premiums and bolster confidence in your MSP validation process by identifying gaps and implementing process improvements.
  • Cost Avoidance—validate eligibility data and identify inaccuracies in coverage information while updating eligibility records to ensure proper payment on future claims. The cost avoidance Advantage—increase confidence claims will be paid correctly, ease the burden on your team to identify and recover overpayments, and reduce the anxiety caused by provider and member abrasion.
  • Recovery—increase MSP post-payment recoveries by employing a highly trained team of professionals with extensive knowledge of specialized recoveries. The recovery Advantage—help fulfill recovery goals and ease the stress of overpaid claims and the burden on internal resources to identify and recoup overpayments.

Download our MSP Advantage product sheet to learn more.

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Audit Advantage for Outpatient Claims

Identify improper payments for the spectrum of outpatient claims while protecting critical provider relationships.

The Problem

  • By 2029, outpatient services are projected to increase by 14.8%, whereas inpatient volumes are expected to decrease by 1.0%
  • Packaging codes under a single APC/APG creates less opportunity to identify audit findings
  • Complex CPT weighting and ever-changing payment rates make it difficult to maintain information and identify coding anomalies
  • Validity of pre-authorized services cannot be determined until service is rendered and medical records are reviewed

The Solution

  • Deploy a team of clinical and audit experts who perform medical record reviews with speed and accuracy to optimize audit findings and recovery efforts
  • Perform level of coding reviews to identify and amend incorrect CPT codes, resulting in a lower APC/APG level
  • Deliver audit findings with a high rate of accuracy to boost recoveries and reduce provider burden
  • Implement a proven outpatient audit program to achieve savings up to $6 PMPY for Medicare Advantage plans and $4 PMPY for commercial plans

Download our Audit Advantage for Outpatient product sheet to learn more.

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Performant Insight™

Performant provides unparalleled insight into our audit and recovery metrics via our online business intelligence and reporting portal, Performant Insight™.

Performant Insight™ is a purpose-built analytics and data processing product for the healthcare industry. Our customers benefit from the ability to predict leads, rapidly assess billing patterns and abuse, and improve access to their data. The technology supports an open data model and allows the health plans to query their entire claims data warehouse within seconds, identify suspected improper payments, and flag potential fraudulent activity. In addition, our solutions are backed by fraud, waste and abuse expertise, world-class customer support, and highly rated security measures.

Our fraud solutions empower customers to improve cost savings and enable data-driven decisions, with easy-to-use tools designed for the everyday business user. Customers can monitor, report, and engage in both pre-defined and ad hoc analysis of all pertinent analytic and recovery metrics, including:

  • Activity by Provider
  • Hit Rate Tracking
  • Audit Status
  • Claim Adjustment Metrics
  • Reporting by Line of Business or State
  • Recovery Aging
  • Trending Over Time
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Clinical Audit

To support a health plan’s cost containment efforts, Performant offers a wide range of audit services (both clinical review and data mining) for all lines of business, including commercial, Medicare, and Medicaid. Additionally, Performant leverages more than 40 years of experience in asset recovery to deliver leading COB/TPL, MSP, and provider recovery services. Our team of highly trained audit professionals includes registered nurses, certified coders, data analysts, recovery specialists, and medical directors brings deep experience with the payment integrity cycle from analysis through appeals to each engagement.

Offering proven industry best practices coupled with a proprietary library of specialized audits, Performant delivers tailored solutions aligned with the payment integrity goals of our clients. Our fast and highly customizable program implementation accelerates savings and recovery, as well as program ROI; and our dedicated team of professionals brings valuable audit and recovery experience and a focus on building long-term relationships.

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Data Mining

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’s 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.

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Medicaid TPL

While regulations support other forms of coverage as primary before Medicaid, there is no single source from which MCOs can easily obtain information on other forms of coverage. Identifying this information can lead to substantial savings for MCOs.

Data simplified. Performant leverages eligibility information from multiple third party liability (TPL) sources to create a repository of other coverage information. The MCO’s enrollment roster is compared against our robust data warehouse to identify any payers that should be primary to Medicaid. Depending on the MCO’s needs, Performant utilizes the newly discovered coverage information to perform cost avoidance, post-payment recoveries, or both.

Savings maximized. Performant’s extensive knowledge regarding specialized recoveries and deep relationships with commercial payers result in substantially higher post-payment recoveries than other Medicaid TPL vendors—all supported by transparent reporting to the plan. The flexibility of our platform enables us to design a TPL program specifically for each MCO’s needs, while our extensive resources and dedicated account management ensure expedited and accurate program implementation. Performant’s identification, cost avoidance, billing, and reclamation solutions ensure payment appropriateness and recover payments made by the plan when Medicaid should have been the payer of last resort.

The Problem

  • An estimated 13.4% (4.6 million) of Medicaid enrollees have access to other sources of health insurance
  • No single database exists for MCOs to identify other coverage information
  • Unidentified primary coverage results in improper payments and higher costs for MCOs

The Solution

  • Leverage Performant’s extensive coverage database and proprietary algorithms to identify other coverage information
  • Deploy Performant’s highly trained team of outreach professionals to work directly with each payer
  • Capitalize on established technology and staff expertise to accelerate cost avoidance and/or post-payment recovery efforts
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Healthcare Provider Overpayment Recovery

Performant's foundation is built on delivering solutions that quickly and efficiently recover funds due to our clients (e.g., overpayments, debts, aged recoveries). With more than 40 years of recovery experience, we have a proven track record of managing accounts, some of which are in the billions of dollars. Performant is the leading recovery audit vendor with true recovery/collections experience and an established collections infrastructure.

Our success speaks for itself:

  • 70%+ recovery rate on non-par providers
  • 95% successful contact rate within three months of national account inventory
  • 99.4% quality rating

Performant’s recovery services include:

  • Aged Provider Debt: Aged accounts are reassigned to Performant rather than written off. For one national client, Performant has recovered more than 30% of the accounts already in recovery for more than one year before assignment with Performant.
  • Newly Identified Provider Recovery: Performant delivers superior recovery rates on overpayment determinations ready for initial recovery, especially for non-participating providers.
  • Comprehensive Audit & Recovery: Coupled with Performant’s audit services, newly identified overpayments are defended through appeal and then efficiently coordinated for provider repayment.

Performant achieves remarkable results because we understand the payment lifecycle and how claims are processed, analyzed, and audited. Our recovery agents are assigned by provider as “account managers”, instead of working on a claim-by-claim basis, resulting in improved communication, mutually efficient interactions, and improved accountability.

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