Pre/Post Pay Data Mining Module

Inefficiencies, redundancy and high overhead are only the tip of the iceberg. Discovering lost dollars based on inaccuracies takes digging deeper. Success is determined by the depth someone is willing to dig. At DataMetrix, we combine years of clinical expertise and a comprehensive data mining system to ensure financial compliance and recovery. DataMetrix has developed a proprietary data mining system incorporating client claims data, utilizing specifically defined algorithms combined with highly skilled and experienced personnel.

DataMetrix identifies areas of revenue recovery including, but not limited to:

• Eligibility
− Tracking and maintaining eligibility roles can be complicated Benefit changes, life changes, and career changes all may impact the employee’s eligibility. Our edits and validation processes capture those changes causing errant claim payments.

• Coordination of Benefits
− Paying strict attention to the information submitted with the claims data, recognizing prior COB events, or retroactively identifying dual coverage opportunities, allows DataMetrix to maximize your savings through the Coordination of Benefits provision of your benefit plans.

• Medicare Billing Compliance Edits
− All claims are run through inpatient and outpatient Medicare-defined edits to identify inconsistencies in coding and billing practices. Medicare billing issues are also addressed with the hospital provider during onsite audit.

• Duplicate Payments
− Pressure to increase automation, to increase individual production, system limitations and overlapping billings are a few of the causes of duplicate payments. The algorithms employed by DataMetrix identify these errant payment situations for quick recovery and the identification of preventative opportunities.

• Contract Compliance Review
− The advent of new technology and the advancements in medical science have cause both facilities and individual professionals to make certain that the contracts with health plans and other insurance carriers cover their costs to deliver care. This has resulted in increasingly complex contracts more difficult to adjudicate. With this in mind it is easy to see how manual calculations can quickly lead to claims overpayments, increased rework, increased interest payments, and ultimately provider abrasion. DataMetrix contract compliance efforts can help you resolve payment issues and educate staff to prevent continuing payment problems.

• ESRD – End Stage Renal Disease
− Making certain that the plan is the primary payer for the ESRD service is just the first step. DataMetrix also makes certain that there is no unbundling and the pharmaceutical packaging and dosage administration is in line with standard medical practice.