Cost Containment
Solution Summary
Along the Claims Continuum
Pre-Payment
Claim Receipt &
Processing
Claim Payment
Finalized
Post-Payment
Claim Payment
Released
PreVent
OPID
Recovery
Subrogation
SURVEY SERVICES
PRODUCT
Prevent
OPID &
Recovery
Subrogation
Survey
Services
DESCRIPTION
Identification and correction of overpayments after a claim has been finalized, but
prior to payment being released
Identification and recovery of overpayments after claims have been paid to the
provider
Identification, investigation and confirmation, and recovery of expenses for an injury
that occurred as a result of a third party
Collection of information pertaining to the existence of OI coverage and accuracy of
subscriber’s information to enable correct payment of claims
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The Accent PreVent Approach
Receipt of Claim
Claim Adjudicated
Pre-Payment Pricer
Payment Released to Provider
PreVent Claim Quality Audit
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PreVent: How it Works
Claims adjudicated by client
Claims data sent to Accent
Proprietary edits are applied
Audit staff validates mispayments
Quality review
Claim corrected by Accent or file returned to client
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The Value of PreVent
Description
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Identification and correction of overpayments
after a claim payment has been finalized, but
before being released to the provider
Claims are audited for a variety of
overpayment reason types, such as:
COB, Duplicates, Contractual Liability,
Exclusions, Global Services, Billing Errors,
Fee Schedule Audits and Medically
Unnecessary Events
Think “Prevention of Overpayments” - thus
PreVent
Value Proposition
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•
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Supplements existing technology with human
intervention
Improves cash flows
Lowers total claims processing costs
Reduces “non-recoverable” overpayments
Results in improved provider and member
relationships
We are the only supplier in the market with
a patent pending on this unique
combination of both technology and
manual intervention
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PreVent Client ROI
Top 10 Payer Saves $19 PMPY
Client’s Challenges
West’s Solution
•
Needed a way to supplement
their current overpayment
identification efforts w/o
impacting timely processing
•
Client partnered with
Accent to develop a daily
prepayment file exchange
process
•
Looking for a solution to
ensure they pay claims
accurately the first time
•
Client provided access to
claims payment and other
ancillary systems
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•
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Looking to reduce
overpayments made to
providers with low
recoverability
Desire to enhance their
provider and member
experience with accurate
claim payments
Minimize leakage and cost of
post-payment recovery efforts
•
•
Accent runs claims
algorithms and audits
claims the day they are
received to identify
overpayments and ensure
timely processing
Upon confirmation of an
overpayment, Accent
Correction Analysts adjust
the claim within the client’s
system to pay accurately
Results
•
Saved this client over
$150,000,000 in overpayments
from occurring
•
Improved Cash Flow
•
Exceeded Quality Standards
•
Exceeded Savings Goals
•
Lowered total claims
processing costs by reducing
claims reprocessed and
remittances
•
Increased
provider/member/ASO
satisfaction
•
Reduced vendor fee
•
Maintained client’s claim
payment timeframe
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Subrogation
Proprietary technology, industry leading performance,
member & client collaboration
IDENTIFICATION
3x MORE CASES THAN INTERNAL OPERATIONS
Sophisticated analytics applied to claims data. Proprietary scoring model and
predictive analysis identifies combinations of diagnosis and procedure codes that
have highest likelihood to be “accident”-related and greatest probability of recovery.
RESPONSE RATES 10%-35% GREATER
INVESTIGATION
Member education and engagement is paramount to success of subrogation recovery.
Trained specialists educate members and take the time to answer questions with a
friendly approach. Response channels include phone, web, mail or fax.
CASE MANAGEMENT & RECOVERY
INCREASED NET RETURNS BY 60%
Specialty subrogation tools maximize returns and include P&C database searches, federal
and state court records, LexisNexis, Westlaw, social media, Google Alerts and more. We seek
the facts of the case, identify all parties and develop the most effective recovery strategy.
Recovery specialists act as an advocate for clients to secure the best possible recovery.
Proprietary analytics
to identify
subrogation claims
Greater member
engagement &
activation
Diligent case
management & expert
negotiation
Higher returns,
lower costs, better
experience
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Subrogation Client ROI
BCBS Payer in the Midwest
Client’s Challenges
•
Antiquated process for
identification of TPL cases
•
Expensive staffing model
•
When investigating
member’s claims for TPL,
client was limited to
letters and outbound
phone calls, resulting in
reduced confirmation
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Limited options for
members to respond
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ROI did not support their
current process
West’s Solution
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Client selected West to
perform TPL services on
its entire population
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Client also intends to
leverage West’s expertise
in this arena to enhance
its processes in
identifying Worker’s
Compensation TPL cases
Results
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We have improved
recoveries by 17% from
the year prior to them
partnering with West
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Cost savings and
efficiencies were
experienced from the
onset of the partnership
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Client was able to focus
on their core competency
and ensure the right
people were in the right
roles in order to maximize
their human capital
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Survey Services
By working in the first party with the administrators, our process is
seamless to the groups. We outreach to
subscribers/members/employees/employers to determine:
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Existence of other insurance coverage
Eligibility / Ineligibility of dependents
Group size
Accuracy of the subscriber’s information to enable our clients to
pay claims correctly the first time
30%
85%-99%
response rates
4%
of contracts
surveyed are
identified as
having other
coverage
Outreach includes a combination of letters and
phone calls (both automated and live).Technology
is backed with human expertise, available to
answer member and group questions in a
customer-friendly manner. Members have the
option to respond via phone, web, mail and fax.
While results vary per customers, on average
we’ve found 3%-8% of survey respondent have
other coverage, resulting in millions of dollars of
potential savings.
A BCBS plan estimated savings of $1,110 for
each positive identification of other insurance.
We customize the frequency,
volume, process and response
methods to meet the client’s needs.
VALUE PROPOSITION
- Minimizes member & group contact
- Technology is backed with human expertise;
available to answer member and group questions in
a customer-friendly manner
- Convenient response options - Phone, Web, Mail,
and Fax
- Previous responses can be utilized in future surveys
- Our system provides automatic follow-up throughout
the treatment cycle if a response is not received
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Survey Services Client ROI
State Teacher’s Association
Client’s Challenges
•
Client’s administrator
does not have the
resources, staffing model
to flex to the group’s high
demands for an annual
project
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Process completed within
a short 8-week period
requiring a 99% response
rate and long call times
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Multiple customizations
required (i.e. letters,
envelopes, courtesy calls
with confirmation
numbers, specialized
nursing home response,
update process, etc.)
West’s Solution
Results
•
West is able to flex
resources (both IT and
agents) to implement on
an aggressive timeline
and handle the influx of
call volumes during a few
months out of each year
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Acting as a first-party
vendor, West mails more
than 185,000 letters and
handles 30,000 calls
during an 8-week period
each year throughout the
project
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West can customize the
frequency and volume of
questionnaires and phone
calls used during the
investigative process
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West achieves an overall
response rate of 99.5%
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4% of contracts surveyed
are identified as having
other coverage
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Multiple response options
are available supporting a
member-friendly process
allowing responses to be
submitted via the most
convenient method for
each individual member
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