What is Payment Intelligence?
AArete’s Payment Intelligence® is a solution designed to deliver actionable findings to the prepay adjudication and post-pay recovery processes by ensuring erroneous payments are identified, understood, recouped and rectified to prevent them in the future
The configuration of a payer’s claims adjudication system affects payment integrity. Many vendors provide on-going payment integrity services; However, AArete’s Payment Intelligence ensures erroneous payments are identified, understood, recouped and rectified to prevent them in the future. Implementing changes in configuration to address payment accuracy ultimately leads to sustained improvements in client profitability. Although some clients engage AArete to perform steady-state reviews, clients also engage AArete prior to go-live (i.e., pre-implementation configuration) or during migrations (i.e., system migration & integration).
Payment Intelligence benefits include:
- Retrospective recoveries
- Remediation of configuration and process gaps
- Increased efficiencies
- Improved regulatory compliance
- Alignment with industry standards and internal policies
- Enhanced provider relations.
Additionally, Payment Intelligence helps:
Optimize medical loss ratio (MLR)
Reduce the financial volatility from resolution of underpayments
Create transparency—both internally (your reimbursement decisions) and externally (market acceptance gleaned from AArete’s intellectual property.
AArete collaborates with clients to customize a solution that addresses their specific needs. Payment Intelligence dives deep to understand root causes and implements solutions with a focus on these six key areas:
Enhance alignment of provider reimbursements with provider contracts to mitigate risk associated with incorrect reimbursements, as well as process improvement to reduce future issues.
Identify opportunities in provider data system setup, validate provider loads, and confirm accurate participation for groups and facilities.
Validate eligibility of benefits, covered services and benefit accumulators, to ensure compliance to regulations dictated by line of business and market.
Ensure policies meet mandated guidelines, identify policy gaps to market standards, and enhance related provider communication.
Review and optimize prior authorization requirements, optimize based on safety and financial requirements, and identify provider education needs.
Identify opportunities in member data system set-ups, cost-share calculators, and confirm reconciliation to revenue and retroactive enrollment/termination.
Fraud, waste and abuse in health care claims: A bad situation worsened by the pandemic
published in BenefitsPRO
Get in touch with AArete’s Payment Intelligence experts
We Are AArete
AArete has worked with 90+ health plan clients with 8 of the top 10 payers by membership with experience in over 40 US states.
By using client-tailored advanced data analytics, our Knowledge Management Center™, and our proprietary methodology, AArete is focused on optimizing payment accuracy while maximizing profitability.
Implementing changes in configuration to address payment accuracy ultimately leads to sustained improvements in client profitability. Although some clients engage AArete to perform steady-state reviews, clients also engage AArete prior to go-live (i.e., pre-implementation configuration) or during migrations (i.e., post-merger integration).