Prepayment Claims Review
There are a thousand ways to code a claim wrong, and one way to code it right. Health plans should only pay claims that are properly coded and documented.
Nokomis finds coding errors and inappropriate and undocumented charges before you pay the provider, saving you 3-7% of your medical claims spend.
Nokomis provides 3 layers of review to find claims errors that others miss, delivering additional savings you would otherwise miss out on:
- Our sophisticated, proprietary claims review engine rapidly applies configurable coding evaluation rules to identify outright errors and flags claims for further review.
- Expert claims reviewers look at each suspect claim, regardless of dollar amount, and either make a payment recommendation based on the information on the claim or request more records if needed to fully assess the claim’s validity.
- With over 25 years’ average experience, our certified coders and claim analysts validate automated findings and apply their expertise to identify claims and claims lines that we recommend for denial.
- Nokomis follows national, state, and product-specific guidelines in reviewing claims so provider challenges and appeals are minimal.
- Detailed records review ensures that the complete picture is evaluated and the most accurate determination is made.
- Nokomis requests records on about 5% of all claims.
- More than half of the savings we identify come from records requests, and our efficient records handling process means there is no lower limit on claims audits. 40% of records audit savings come from claims with allowed amounts under $3,000.
- When practices submit records, we review the requested records to see if the charges are justified.
Nokomis isn’t afraid to request records on even small-dollar claims. In fact, 40% of the savings our clients get from records review comes from claims with allowed amounts of less than $3000. Savings of $1252, $354, or even $112 are still savings. And you still pay just a flat percentage of the savings that stick.
Nokomis’s efficient approach to records requests and records review means that we can help you avoid paying even the smallest claim in error. Those small claim errors can add up to real money.
100% of claims are returned within 24 hours with a recommendation to pay or to deny for one or more specific reasons, or that we are requesting additional records. We take on the responsibility to request and receive records. Once records are received and reviewed, we forward the claim back to the plan with a recommendation to pay or to deny based on one or more specific reasons (or a notation that records were not received and to deny for lack of documentation). We send you a report of our findings on all claims where we requested records.
Our efficient process and fast turn-around keep you within timely payment deadlines.
There are no up-front fees, no implementation fees, and no monthly minimums so there is no expense budget to worry about. You only pay a percentage of the savings that stick. And because we typically fall in the workflow after all other adjudication, repricing, and reviews, these are real savings. Without Nokomis you are paying 100% of every claim error we would have found. With Nokomis, you only pay a small percentage of what we find.
Nokomis fees are usually paid as medical expenses and can be billed on a per-claim basis so they can be included in stop-loss and other member-specific accumulators.
Because Nokomis reviews claims before they are paid and because we use only standard industry, national, local, and program-specific coding rules as the basis for our business rules and experience-based audits, our clients receive provider and member grievances and appeals on less than 0.5% of claims reviewed.
Our surgical approach to records review minimizes provider and member friction.
Many health plans use multiple layers of coding and claims review. Nokomis finds the claims errors that others miss.
If you already use a coding review solution, we find additional errors that they missed. If you already use a high-dollar claims review, we will request records on claims for errors they chose not to pursue. Thanks to our 3-step process, we can usually find 3-7% additional savings regardless of the other services you already use.
Much of the savings we find is in areas others can’t or won’t review. 40% of the savings we identify through claims review comes from claims with allowed amounts of less than $3,000; 60% for claims under $8,000 in allowed amounts. We are happy to work alongside other payment integrity vendors because Nokomis looks at claims other don’t.
Nokomis works regardless of other payment integrity solutions you might have. We typically fit into the workflow after all other adjudication, repricing, and reviews, and just before the claim is ready to be paid, allowing us to identify any errors the others have missed.
We don’t have to be the only payment integrity vendor you use, we just want to be the best.
We can handle most file formats for inbound (adjudicated) claims and claims returned to the plan.
Nokomis insists on multiple rounds of testing, so implementation typically takes 8 and 14 weeks. Our implementation process also includes configuring the system to reflect your product lines and the specific sensitivity levels for certain providers and groups.
In most cases, your day-to-day interaction with Nokomis is fully automated and can occur without manual intervention.
Our thorough, flexible (and no cost) implementation and configuration ensures that our system is set up to reflect your needs and situation, minimizing issues and avoiding manual intervention once we go live.
The bottom line is that Nokomis makes your plan more competitive. Lower claims costs mean lower premiums which translate to more competitive offerings.
