30 page special report on emerging COVID-19 related FWA schemes
AI compares each provider’s claims and coding practices to their peers, identifies outlier behavior, and proactively engages providers to improve claim integrity and bring down pre-claim costs with a Provider Self-Monitoring and Communication Portal.
Claim Pattern Analysis – AI reviews use of codes and creates dynamic peer groups for each specialty
Provider Scores – AI then analyzes all claims to identify providers whose billing behavior differs significantly from their peer group. Provider outlier status is re-evaluated every quarter.
Provider Self-Monitoring & Communication Portal – informs providers about their billing patterns and when appropriate explains why the provider was identified as an outlier.
Contact providers electronically or through letters that provide information on accessing the Provider Scope portal with a one-time access code for security. Single sign-on (SSP) available.
Portal displays useful visual data and insights about the provider’s billing patterns and why they were identified as an outlier.
Certified coder staff available to discuss why the provider has billed the way they have, provide coding best practices, or if there are valid reasons for their billing patterns.
If provider’s billing practice remains a concern for a quarter after the initial contact, a second communication will be sent along with updated trend information within the platform.
Health plans are notified of providers whose billing practices remain a concern for two consecutive quarters if they don’t have a justifiable reason for their outlier billing pattern.
Plans will have ability to track provider engagement with the online portal.