hci service catalog 2009_singlepages
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HCI Service CatalogTRANSCRIPT
CLINICALLY VALIDATED FRAUD, ABUSE AND OVERPAYMENT PREVENTION >A Verisk Health Company
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What Will the Future hold?
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by 2013 annual health care costs Will surpass $3 Trillion.
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losses from Fraud & Abuse Will reach up to
$300 Billion.
that’s a loss of
$820 Million every day.
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that’s a loss of
$566 Thousand every minute.
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Clinically validated fraud, abuse and overpayment prevention >
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Prevent Fraud | Improve Accuracy | Reduce Costs
fraud Stops here
Fraud stops Now.
We provide private and public sector claims payors with a comprehensive suite of clinically validated fraud and abuse prevention services. Let us help you maximize claims accuracy and minimize payment waste.
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say hello to
Prevent Fraud | Improve Accuracy | Reduce Costs
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do you have a fraud Problem?We have your Solution.
www.hcinsight.com
Prevent Fraud | Improve Accuracy | Reduce Costs
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We have the tools to help you stop fraud, abuse and overpayment.
Robust data Warehouse
25 MILLION MEMBERS >
1.3 MILLION PROVIDERS >
$90 BILLION PAID CLAIMS >
450 MILLION CLAIM LINES >
Clinical revieW
MEDICAL CODING SPECIALISTS >
CLINICAL INVESTIGATIVE UNIT (CIU) >
PHYSICIANS, NURSES AND DENTISTS >
NATIONAL CLINICAL PANEL >
our process Works.
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Complete service
ACCOUNT SUPPORT TEAM >
DEDICATED CLINICAL RESOURCES >
AD HOC AND CUSTOM REPORTING >
APPEAL SUPPORT AND RESPONSE >
Robust data Warehouse
25 MILLION MEMBERS >
1.3 MILLION PROVIDERS >
$90 BILLION PAID CLAIMS >
450 MILLION CLAIM LINES >
Advanced technologyOVER 3 MILLION ALGORITHMS >
DYNAMIC CLAIM AND PROVIDER SCORING >
CUSTOMIZABLE RULES AND PARAMETERS >
REAL-TIME CLAIMS PROCESSING >
Clinical revieW
MEDICAL CODING SPECIALISTS >
CLINICAL INVESTIGATIVE UNIT (CIU) >
PHYSICIANS, NURSES AND DENTISTS >
NATIONAL CLINICAL PANEL >
www.hcinsight.com
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CRA
Fraud, abuse & overpayment savings analysis for claims payors >
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Identify Fraud | Expose Risk | Quantify Savings
We can Boost
your Bottom Lineand We’ll Prove It Free
of charge.
Identify Fraud | Expose Risk | Quantify Savings
Let us quantify your annual fraud, abuse and overpayment savings and identify key areas of risk and waste.
“HCI has prevented the payment of over $5 million in inappropriate charges.”– Michael De Chellis
Operating Engineers Trust Funds Inc.
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Results> Measure PMPM savings projections> Align areas of risk with tailored solutions> Understand fraud and abuse program ROI
Features> Comprehensive analysis on 24 months of data> Analysis by cutting-edge software systems> Identification of overpaid claims and dollars> Clinical review on a subset of suspect claims> Detection of questionable provider activity> Discovery of risk areas and vulnerabilities> Detailed web and hard-copy reporting> Analysis findings over 95% accurate> Results in just 4–6 weeks after receipt of data> Explanation and onsite presentation of findings
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
Fraud Stats3% – 10% of the nation’s annual health care outlay is lost to fraud. By 2013, costs could eclipse $300 billion.
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US health care fraud projections for 2010 – 2013 / 3 – 10% loss
(In
Billi
ons)
the
Problemthe
Solution
$262.4
$277.0
$293.1
$311.1
$78.72010 2011 2012 2013
$83.1$87.9
$93.3
10% Loss
3% Loss
www.hcinsight.com
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Fraud, abuse & overpayment prevention for professional health care claims >
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it takes a
Clinical Expert
to diagnose Fraud
Prevent Fraud | Improve Accuracy | Reduce Costs
“We have experienced positive changes in provider billing habits resulting in significant savings.”
– Mary Alice Garcia, BA, CPCMedicaid MCO
Maximize your claims payment accuracy, identify fraudulent providers and reduce your professional claims costs.
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Prevent Fraud | Improve Accuracy | Reduce Costs
Fraud Stats3% – 10% of US physician and clinical care outlay is lost to fraud. By 2013, losses could reach $63 billion.
Results> Reduce expenditures up to $5 PMPM> Improve claims payment accuracy up to 10% > Increase annual profitability up to 5%
Features> Prepayment analysis on 100% of professional claims> Clinical review on all suspect claims and providers> Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring> Highly customizable rules and parameters> Real-time claims processing and ad hoc reporting> Clinically-driven appeals support and response> Daily notification of suspect providers and claims> Easy to use web-based application> Total professional claims cost-containment solution
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
the
Problemthe
Solution
10% Loss
3% Loss
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Fraud Projections for Physician & Clinical Services 2010 – 2013 / 3 – 10% Loss
(In
Billi
ons)
$55.2
$57.7
$60.4
$63.6
$19.1$18.1
$17.3$16.62010 2011 2012 2013
www.hcinsight.com
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Fraud, abuse & overpayment services for dental claims >
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Prevent Fraud | Improve Accuracy | Reduce Costs
let our Dentists Drill into your Claims.
Optimize your claims payment accuracy, pin-point fraudulent providers and lower your dental claims costs.
“HCI clients have access to the most comprehensive code editing and profiling application ever developed in the dental payor industry.”
– Dr. Jeff DaveeHealthCare Insight®
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Prevent Fraud | Improve Accuracy | Reduce Costs
Fraud Stats3% – 10% of America’s dental care outlay is lost to fraud and abuse. By 2013, losses could approach $13 billion.
Results> Reduce expenditures up to $4 PMPM> Improve claims payment accuracy up to 10% > Increase annual profitability up to 5%
Features> Prepayment analysis on 100% of dental claims> Clinical review on all suspect claims and providers> Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring> Highly customizable rules and parameters> Real-time claims processing and ad hoc reporting> Clinically-driven appeals support and response> Daily notification of suspect providers and claims identified> AADC Certified Dental Consultant review and support> Full-service professional claims cost-containment solution
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
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Fraud Projections for Dental Services 2010 – 2013 / 3 – 10% Loss
the
Problemthe
Solution(I
n Bi
llion
s)
$10.6
$11.1
$11.6
$12.1
$3.2$3.3
$3.5$3.6
10% Loss
3% Loss
2010 2011 2012 2013
www.hcinsight.com
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Fraud, abuse and overpayment prevention for facility claims >
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Prevent Fraud | Improve Accuracy | Reduce Costs
Avoid overpayment
Trauma With our
facility bill Experts.
Elevate your claims payment accuracy, identify fraudulent providers and decrease your facility claims costs.
“HCI customers using this service consistently realize facility claim savings of 15% – 30%.”
– Darin Johnson, MBAHealthCare Insight®
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Prevent Fraud | Improve Accuracy | Reduce Costs
Fraud Stats3% – 10% of the national outlay for facility claims is lost to fraud and abuse. By 2013, losses could exceed $99 billion.
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Fraud Projections for Facility Claims 2010 – 2013 / 3 – 10% loss
the
Problemthe
Solution(I
n Bi
llion
s)
$83.0
$87.7
$93.2
$99.3
$24.9$26.3
$28.0$29.8
10% Loss
3% Loss
Results> Reduce expenditures up to $4 PMPM> Improve claims payment accuracy up to 10% > Decrease targeted claim costs up to 30%
Features> Prepayment analysis on 100% of facility claims> Clinical review on all suspect claims and providers> Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring> Highly customizable rules and parameters> 24-hour turn-around after receipt of records> Signed settlement agreements to eliminate balance billing> DRG audit, validation and repricing services> Claims adjustment based on state and payor standards> Fee negotiation by highly trained professionals
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
2010 2011 2012 2013
www.hcinsight.com
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Fraud, abuse & overpayment prevention for pharmacy claims >
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Prevent Fraud | Improve Accuracy | Reduce Costs
Just the Right Dose
of pharmacy
Fraud Prevention
Strengthen your claims payment accuracy, isolate fraudulent providers and reduce your pharmacy claims costs.
“We have a responsibility to protect our client’s benefit dollars and HCI makes that easy for us.”
– Renee HaasEmployee Benefit Management Corp. (EBMC)
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Prevent Fraud | Improve Accuracy | Reduce Costs
PharmaClaim
Fraud Stats3% – 10% of US pharmacy claim outlay is lost to fraud. By 2013, losses could exceed $30 billion
Results> Reduce rising pharmacy expenditures> Improve Rx claims payment accuracy> Increase annual profitability
Features> Prepayment analysis on 100% of pharmacy claims> Clinical review on all suspect claims and providers> Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring> Highly customizable rules and parameters> Real-time claims processing and ad hoc reporting> Clinically-driven appeals support and response> Daily notification of suspect providers and claims identified> Easy to use web-based application> Full-service pharmacy claims cost-containment solution
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
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Fraud Projections for Pharmacy Claims 2010 – 2013 / 3 – 10% loss
the
Problemthe
Solution(I
n Bi
llion
s)
$25.6
$27.2
$28.9
$30.8
$7.7$8.1
$8.7$9.2
10% Loss
3% Loss
2010 2011 2012 2013
www.hcinsight.com
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Fraud, abuse & overpayment prevention for vision claims >
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let our Clinicians detect
your payment Blind Spots.
Prevent Fraud | Improve Accuracy | Reduce Costs
Improve your claims payment accuracy, detect fraudulent providers and minimize your professional claims costs.
“HCI goes to bat for the client and the patient to be sure the provider is being fair and just.”
– Orlo L. “Spike” DietrichThe Ansley Group
Prevent Fraud | Improve Accuracy | Reduce Costs
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Fraud Stats3% – 10% of America’s outlay for other health care services (including vision care) is lost to fraud and abuse.
Results> Reduce annual claims expenditures> Improve vision claims payment accuracy> Increase overall profitability
Features> Prepayment analysis on 100% of vision claims> Clinical review on all suspect claims and providers> Code Validator Pro® — Rules-based editing > Fraud Finder Pro® — Provider profiling and scoring> Highly customizable rules and parameters> Real-time claims processing and ad hoc reporting> Clinically-driven appeals support and response> Daily notification of suspect providers and claims> Easy to use web-based application> Full-service vision claims cost-containment solution
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
www.hcinsight.com
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Fraud Projections for Other Health Services 2010 – 2013 / 3 – 10% loss
the
Problemthe
Solution
10% Loss
3% Loss
2010 2011 2012 2013
(In
Billi
ons)
$7.2
$7.5
$8.0
$8.4
$2.3$2.4
$2.5
$2.1
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poWered by biologics, inc.
Improved patient outcomes, therapeutic analysis and cost management for oncology claims. >
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Elevate Care | Improve Satisfaction | Manage Costs
your Therapeutic Solution for Rising
Oncology case costs.
Enhance patient care through improved outcomes, increase provider satisfaction and manage oncology claims costs.
“OncologyClaim Insight™ guarantees that the most appropriate plan of treatment is delivered and that patients receive the highest level of clinical support and care.”
– Brian SmithHealthCare Insight®
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Elevate Care | Improve Satisfaction | Manage Costs
poWered by biologics. inc.
Cancer Care StatsCancer is a complex and costly disease. By 2013, cancer care costs could reach up to $130 billion annually.
Results> Elevate patient care and outcomes> Increase provider satisfaction levels> Realize a tangible ROI of more than 8:1
Features> 100% of oncology cases reviewed for eligibility> Plan of treatment reviewed to ensure compliance with evidence-based guidelines and best practices> Oncology Certified Nurses (OCNs) guide patient care> Prompt and accurate claim reimbursement> Drugs and claims analyzed to prevent overbillings> Differentiated approach optimizes outcomes> Physician approval and detailed savings reports> Access to expert oncologist advisory panel> Powered by industry leader Biologics, Inc.
Next StepsContact us for a complimentary Cost Reduction Analysis.Call 1.877.619.5557 or email [email protected] today.
(In
Billi
ons)
the
Problemthe
Solution
$109.6
$115.6
$122.3
$129.9
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www.hcinsight.com
Cost Projections for Cancer Care 2010–2013 / 5% of personal health spend.
2010 2011 2012 2013
Prevent Fraud | Improve Accuracy | Reduce Costs
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CLINICAL REVIEW BY MDs, RNs & DDS’ >
PREPAYMENT SaaS SOLUTION >
TOTAL PAYOR CUSTOMIZATION >
REAL-TIME CLAIMS PROCESSING >
DETAILED AD-HOC REPORTING >
APPEALS SUPPORT & RESPONSE >
IMMEDIATE REALIZATION OF ROI >
SOLUTIONS FOR ALL PAYOR TYPES >
Why you’ll Like Us.
memberships & accreditations
P Phone 877.619.5557
F Fax 801.285.5801
E Email [email protected]
W Web www.hcinsight.com
R HCI Fraud Resources www.profilermag.com www.stophealthcarefraud.com
S Connect With HCI Twitter | Facebook YouTube | Linkedin
M MailHealthCare Insight10897 S. River Front ParkwaySuite 200South Jordan, UT 84095
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hoW to Contact Us.
© 2009 HealthCare Insight – A Verisk Health Company. HealthCare Insight, PhysicianClaim Insight, DentalClaim Insight, FacilityClaim Insight, PharmaClaim Insight VisionClaim Insight, Code Validator Pro and Fraud Finder Pro are registered service marks and trademarks of HealthCare Insight. All other product or corporate names are trademarks or registered trademarks of their respective companies. Fraud loss figures based on Centers for Medicare & Medicaid Services (CMS) spending projections and National Health Care Anti-Fraud Association (NHCAA) loss estimates.
HealthCare Insight10897 S. River Front ParkwaySuite 200South Jordan, UT 84095
Phone 877.619.5557Email [email protected] www.hcinsight.com