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Program Integrity: Prepay Review & Prevention

The most logical way to avoid overpaying for fraudulent or incorrectly coded claims is to not pay for them in the first place.  However, many environmental variables (e.g., payment policy complexity, provider contracts, payment system and resource limitations, and prompt-pay requirements) present significant challenges to this objective.  Still, the industry as a whole remains admirably focused on finding ways to improve this preventive approach.  Early results validate the promise of detection and prevention sooner in the payment process, but have often resulted in overloading a manual prepay review process. 

Truven’s Payment Integrity Enterprise Prepay Risk Management Solution is a comprehensive set of Software-as-a-Service (SaaS) components that are designed to improve the efficiency and effectiveness of your prepay initiative.  


Solution Highlights

  • Advanced Predictive Models – Patent pending predictive modeling approach we employ is revolutionary in healthcare.  Our predictive analytics solution utilizes robust, non-parametric statistical techniques that are not constrained by data distribution assumptions as are parametric statistical techniques or independence to evaluate claims, providers and beneficiary data to determine if behavior is “abnormal”. Our model is not restricted to known cases, but adapts and identifies new and emerging abnormalities as new information is received.
  • Powerful Peer Group Analytics – Leverages time-proven methods of population and case-mix adjusted peer group comparison metrics to the investigators fingertips for consideration in prepay analysis.  We provide this information in our Investigator Workstation to further inform analyst review and decision-making.
  • Claim Edit Analytics – Our claim edit analytics include industry standard clinical edits, residing within real-time analytical technology, to identify incremental savings during the payment authentication scoring process.  Truven provides an edit analytics “landing page” within our forensic investigator workstation for claim or transaction error assessment analysis.  
  • Workflow Strategy Tool – A “managed learning environment” and workflow process automation environment that provides the ability to monitor and quickly adapt to changing or emerging patterns of aberrant behavior associated with fraud or abuse.  Our design allows:
    • Trigger thresholds or sub-strategies to target populations differently
    • Queuing methodology to automate prioritization and tailor workload (claims or providers sent) to existing FTEs for action
  • Investigator Workstation – A fully integrated Investigator Workstation component allowing users to easily reference the breadth of information for on a specific claim or provider.  This includes NCCI edit results, predictive model scoring, and peer group comparisons – which together support more a effective and efficient method of dealing with identified claim issues.

Isn’t it time to put our three decades of experience in fraud detection to work for your program?

Learn more about our program integrity solutions.