Health plans lose millions of dollars a year by overpaying claims that are incorrectly coded, billed, or processed. Our payment optimization solution includes pre- and post-pay claims payment accuracy services to help plans pay the right claims for the right amount at the right time.

Payment accuracy across the life of your claims—for every life of your plan

  • Claims editing, data mining, and provider auditing services across Medicare, Medicaid, and commercial lines of business
  • Pre- and post-payment services that are customized to your plan’s unique provider environments, ensuring correct payments for both contracted and non-contracted providers
  • Advanced technologies, coupled with years of clinical audit, technology and analytics expertise, allows us to find the veins of gold in your claims data and deliver maximum value back to your plan

You’ll find more information on our Coordination of Benefits solution here.

Payment optimization solution

High-dollar bill review

Performed after claims are adjudicated but before they’re paid, our high-dollar bill review service audits select claims to proactively and substantially reduce bill totals and prevent unnecessary revenue loss.

Beyond these immediate benefits, our high-dollar bill review also delivers long-term benefits to your plan by uncovering flaws in your claims processing, often resulting in improved provider contracting processes and billing practices.

  • Utilizes our proprietary algorithms to identify claims that the payer can deny at the line item on a pre-pay basis
  • Reviews contracted and non-contracted inpatient claims paid at a percentage of billed charges
  • No medical records required

Claims editing

An automated service that proactively prevents inaccurately coded claims from being paid, our pre-pay claims editing solution quickly reviews high volumes of claims data to identify patterns and anomalies that can impact payment. Our proprietary technology blends rules-based logic with clinically and medically developed data intelligence.

  • Analyzes claims to accurately and efficiently identify provider submissions not in compliance with your plan’s policies, contracts, and billing standards for physician, inpatient and outpatient services
  • Applies highly sophisticated algorithms to evaluate issues related to eligibility, duplicates, National Correct Coding Initiative (NCCI), Medically Unlikely Events (MUE), and others
  • Handles claims from inpatient and outpatient facilities, ambulatory surgery centers, inpatient rehab facilities, and physicians

Data mining

Our data mining service is performed post-claims payment to identify claims that have been overpaid due to adjudication errors. billing errors, or contract language. Data mining services can be deployed to a large array of health plan offerings, including at-risk commercial, Medicare Advantage, Medicaid Managed Care and state Medicaid plans, as well as third-party administrators

  • Blends rule-based logic with pattern recognition
  • Easily customized to each client’s policies
  • Multi-year analyses capabilities

If you think you’ve fully addressed payment integrity, think again

Meet ReThink™

Our ReThink cloud-based platform is the foundation of our payment optimization solution. This fully integrated software platform supports multiple payment accuracy processes on both a pre- and post-pay basis. Unlike most vendors’ siloed platforms, the ReThink platform enables our editing, clinical auditing, and data mining solutions to talk and share data, increasing efficiencies, productivity, and financial results for health plans.

Discovery Health PartnersPayment Optimization resources for healthcare payers and health plans