Forensic Claims Solutions

Predict the future of your next claim payment In the labyrinth of healthcare payment integrity, navigating the complexities of claims and payments can be daunting. Industry standard rules, coding practices and contracted rates often seem shrouded in mystery, leaving payers and providers uncertain about what lies ahead. However, amidst this uncertainty, we have created a predictive claims payment system called Sleuth. Sleuth is not just another tool in the realm of healthcare claims management; it's a game-changer, revolutionizing the way we predict and understand future claim payments. With its cutting-edge algorithms and data analytics, Sleuth goes beyond traditional methods, offering a glimpse into the future of reimbursements with unprecedented accuracy. At the heart of Sleuth's predictive prowess lies its advanced ai capabilities. By analyzing vast amounts of historical claims data, Sleuth identifies patterns, trends, and correlations that elude the human eye. It learns from past claim outcomes, taking into account various factors such as diagnosis codes, procedure codes, provider information, and industry practices to create predictive models tailored to categories of claim payments such as; inpatient, outpatient, ancillary and physician. But Sleuth doesn't stop there. Unlike static prediction models that become obsolete over time, Sleuth evolves and adapts, incorporating real-time data updates and refining its algorithms to reflect the ever-changing reimbursement landscape. This approach ensures that Sleuth's predictions remain accurate and reliable, even in the face of new regulations, market shifts, and emerging trends. So, how exactly does Sleuth peer into the future of claim payments? Let's delve deeper into its capabilities: Precision Forecasting: Sleuth leverages its predictive models to forecast the likely payment outcomes for individual healthcare claims with remarkable precision. By considering a myriad of variables and their interplay, Sleuth provides stakeholders with actionable insights into expected reimbursement amounts, enabling them to plan and strategize effectively. Risk Mitigation: In addition to predicting claim payments, Sleuth identifies potential risk factors that could impact reimbursement, such as coding errors, billing discrepancies, or coverage limitations. By flagging these risks early on, Sleuth empowers providers and payers to proactively address issues, reducing the likelihood of claim denials or underpayments. Optimization Strategies: Armed with Sleuth's predictive analytics, health organizations can optimize their revenue cycle management processes. Whether it's negotiating contracts or setting pricing strategies, Sleuth equips stakeholders with the insights needed to maximize financial performance and operational efficiency. If you would like to learn more please reach out to me at mmcgauley@forensicclaim.com or follow our company page https://lnkd.in/eKz7KDyx

When it comes to spending, healthcare is second to none. CMS National Health Expenditure Data projects spend in the Healthcare sector to grow 2 to 3 percent per year. In 2022 Healthcare Expenditures were $4.5 trillion including private and government plans. Private carrier spending grew 5.9% to $1.289 trillion dollars. As you can imagine, there has been a lot of efforts by Payers to control reimbursement errors and despite all these efforts we still have significant problems. Currently 3-7% of all errors are of the overpayment variety, while underpayments comprise considerably less (approx. 50% of the overpayment error rate). If we take a 6% overpayment rate and apply that to private payer spend of $1.289T we get an astounding $77B dollar overpayment opportunity. You might be asking yourself; how much of that $77B is related to contract payment errors? Are you sitting down? Depending on the Payer the numbers range from 30% to 50% of a normal payment error rate of 3-7%. That’s right, the total overpayment projection for private payers is $23B to $38B. These errors are preventable but have been difficult to stop because the data is constantly changing. Contracts are renegotiated annually and carveout’s are loaded improperly or the terms are just too complicated for the payment platform and need to be adjudicated manually. What do we do to stop the bleeding? Here at FCS, we have developed a patent pending product Sleuth© aimed directly at bringing down the error rate for contracts. Sleuth© deploys ML and multi variate statistical algorithms to identify every contract overpayment for every provider in your network. We do it quickly and accurately. We share the errors as they are happening and give you the information needed to fix them. If this sounds interesting to you reach out to us. We’d love to talk.   Mike McGauley Founder – Forensic Claims Solutions E: mmcgauley@forensicclaim.com C: 502-649-2065 https://lnkd.in/gQ3wejFj

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Need help enhancing hit rates and lowering provider abrasion for APR and MS DRG chart reviews? Our analytical packages model diagnosis and procedure codes that influence institutional reimbursement rates and recommend claims to select as potential overpayments. Contact us today to learn how we moved hit rates from 9% to 33% for a major health insurance payer! Founder: Michael McGauley email: mmcgauley@forensicclaim.com https://lnkd.in/edkbAdn9