The Cost of “Pay and Chase”

An estimated $340 billion healthcare dollars are lost annually to fraud, waste and abuse in medical billing mistakes.  This is an enormous blow to health insurance organizations, particularly when some of these dollars are literally thrown away trying to fight fraud with inferior tools and strategies.

Insurance organizations focus on fraud because of the need for more cost containment, and pressure on payers to prioritize resources based on their financial impact. Healthcare payers must address the economic issues of fraud and medical billing mistakes to survive in an increasingly competitive landscape. Because managing costs is imperative, many payers must determine where to reduce operational and medical expenses; a comprehensive fraud, waste and abuse program may help reduce both.

Most healthcare organizations employ the ineffective “pay and chase” strategy.  Post-payment claims review situations have proven to fail to recover the majority of money paid out to faulty claims.  To add insult to strategy-injury, some payers’ in-house fraud detection programs are understaffed and ill equipped to assess suspicious claims. In addition, post-payment technology and methods can take months to detect and analyze the problem. By this time, payers are less willing to negotiate settlements, and truly criminal organizations may have already changed locations and schemes.

Payment Integrity and Revenue Cycle Management

  • Coding and Billing errors in your claims can cause revenue cycle management issues
  • Finding those errors before the submission of a claim can help solve that problem
  • The Centaur learns about coding errors from humans, analyze claims in real time, and point out medical billing mistakes that need to be corrected
  • Why should a $20 medical billing mistake delay thousands of dollars’ worth of revenue?

The Centaur – AI for Fraud Prevention

  • Cognitive computing that learns from humans
  • Targeting Healthcare Fraud
  • In the cloud, on your premise, or somewhere in between

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