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Health Plan Overpayment Recovery

Health Plan Payment Integrity

For two decades, FRG has set the standard for Health Plan Payment Integrity – and Contract Configuration.

Health Plan Payment Integrity
“We utilize several payment audit firms at our insurance company. Month after month FRG continues to find items that the national audit firms miss. FRG is quick to respond to changes in our business and have provided white papers to me and my staff understand the impact and root cause of why overpayments occur.”
VP Finance, National Health Plan
“I can’t say enough about the staff of FRG. The service they’ve provided our business is the absolute best. Always prompt, always professional and always proactive, the experts at FRG take care of our provider reporting so we can take care of business.”
Director of Financial Recovery

FRG provides expert overpayment and recovery services to help health plans balance the efficient payment of claims with their financial fitness. Our team provides a full spectrum of services from fee-per-claim accuracy audits to 100% contingency over payment assessments and collection support.  We serve substantial national clients and niche market plans, each with the same level of quality and service that makes our firm unique.

Detecting claims payment errors in a high-volume healthcare environment requires a systematic approach. FRG combines a Statistical Analysis Software (SAS®) rules engine with line-item inspection by expert auditors, each with over 20 years of experience, to mine multiple years of claims data for payment errors and bring them to your attention.  Our no-chalk approach keeps our toes off the line.  After we abstract your contracts, we filter out misleading information and dubious overpayments to deliver only actionable recoveries.

Computerized adjudication systems, when configured correctly, can deliver significant efficiency for a health plan claims department. However, when there is an error in loading a contract, tens of thousands of dollars in overpayments can be issued each month. FRG provides a post-adjudication and payment audit service that can help you recover millions of dollars in undetected payment errors.  Our team also manages the collections process through issuing letters or posting edits as offsets to your claim system.

Some of the smallest errors can add up. Case rates change and don’t get updated. Claims get billed twice and the second claim is not denied.  Patient identifiers change but retroactive eligibility revocation is missed. Smaller claims overpaid by just a few dollars may not be worth the time and effort to recover unless there are a substantial number of overpaid claims. Our expertise covers Fee for Service, Capitation, DRG, Per Diem, Carve-Outs, Outpatient Surgery, Billed Charges, and a variety of bundled payment arrangements for national Medicare plans and ten state-based Medicaid managed care plans.

Claims administrators should consider a few things when determining whether or not to seek repayment. These include:

  • The statute of limitations on the claim
  • Provider community norms
  • The dollar amount to be recovered
  • Provider abrasion potential

FRG can help you decide what to pursue and provide white papers on how to correct your system configuration. Fees for overpayment analysis are contingent on the amount recovered and may include a set-up fee. Fees for payment integrity audits will be charged based on the scope of the audit and the complexity of the impacted network.

FRG’s Audit & Recovery Results at a Glance

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Medical Claims Audited Yearly
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Average Recovered Overpayments per Client
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Medical Claims Audit & Recovery Experience

Making Sense of Medical Claims Data

Employing proprietary healthcare software programs, FRG has streamlined and improved medical claims audit outcomes to greatly reduce overpayments. Data mining programs run against large claims databases extracting only the claims identified as “outliers” in seconds. These programs enable an unparalleled level of data mining defined by quantitative/qualitative healthcare and financial analytics criteria.

  • Analysis of health plan-specific weaknesses
  • Broad industry trends and issues
  • Provider history and experience
  • Trends in services flagged by historically high levels of overpayment