We support you throughout the entire claims payment cycle with seamlessly integrated services.

We offer a comprehensive suite of payment integrity products including claim review, fraud monitoring and detection, repricing, consulting, audit, and reinsurance claim adjudication and management.

Nokomis is comprised of top-notch industry experts who have a detailed understanding of claim complexity and risk areas. Together with the power of our proprietary ClaimWiseTM system, we provide services that improve payment accuracy, increase compliance, and generate long-term savings.

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Claim Review

We provide comprehensive, customized payment integrity services to health plans, third party administrators and payors. Our highly experienced and knowledgeable team of certified healthcare coders and claims analysts understand the risk areas inherent in medical claims.

We apply sophisticated analytics to find patterns within the data which may indicate fraud, waste, and abuse. We are constantly building and updating our rules to enhance our clients’ claim savings.

Where applicable, we obtain medical records and ensure that all charges are correct and supported by documentation. We review both professional and facility claims and, when appropriate, we conduct line-item audits on hospital claims.

Our 360 degree approach to claims is proven to find savings for our clients, even if the client uses their own code edit software or works with another claim review company.

Payment integrity/ claim review features

  • Review 100% of post-adjudicated, pre-paid claims to ensure accuracy prior to payment being made
  • Rapid turnaround: all claims are returned to client within one business day
  • Typically save plans 4% to 9% (or more) of their claim spend, and appeal rate is less than 1%
  • All reviews and edits are based on industry-standard coding and billing requirements and standards

Nokomis distinguishes itself from its competitors through the following features:

  • Highly efficient at requesting and reviewing medical records: Nokomis typically generates greater savings from record reviews when compared with competitors
  • Experts at finding fraud: Nokomis saved a New York Medicaid plan over $2.5 million in one year by uncovering a group of fictitious providers
  • Ease of implementation: Nokomis does the “heavy lifting” wherever possible in order to minimize client set-up efforts
  • No-risk solution: fees are contingent upon identified savings

Payment integrity services include five main areas of focus:

Code edits

  • 100% of claims reviewed for coding accuracy to ensure that only correct claims are paid
  • All code edits supported by external sources
  • Hundreds of edits are applied across claims to ensure identification of each coding error

Clinical reviews

  • Review and identify claims that are inconsistent with industry norms
    • Overutilization of services
    • Length of stay not supported by documentation
    • Services which may not be medically necessary
    • Level of service assignment
    • Emerging and experimental procedures and services
    • Excessive drug usage
    • Potentially cosmetic procedures
    • Questionable services based on diagnosis

Fraud, waste and abuse

  • Sophisticated analytics are applied to continuously monitor and identify suspicious providers and members
  • Sanctioned provider rosters used to identify non-payable claims

Medical record review

  • Request and review records on both large- and small-dollar claims to ensure that codes and charges are supported by documentation
  • Allows for deeper investigation of providers who have demonstrated a pattern of submitting incorrect claims
  • Examples of the types of clams that often yield savings from record review include:
    • Evaluation and management (E&M) level of service
    • Incorrect procedure codes based on operative report
    • E&M with procedure – abuse of 25 and 59 modifiers
    • Incorrect ICD-10 diagnosis coding
    • Time-based charges to ensure rounding and time calculations are correct
    • Chemotherapy, other drug infusion/administration charges – to ensure accuracy of drug units, infusion codes, and charges
    • Radiation therapy charges, often incorrect code assignment
    • Home health, interpreter, transportation, personal care attendant charges
    • Diagnostic testing not supported by diagnosis
    • Drug screens not supported, not correctly billed, excessive
    • Hospital charges not separately payable

Administrative edits

  • Review claims for administrative issues that may have arisen from the primary payor’s adjudication
    • Duplicate claims/ claim lines
    • Provider network status incorrectly applied
    • Incorrect fee schedule applied
    • Other edits that ensure that claims are accurate prior to payment

Case Study

A 56 year old male underwent cardiac valve replacement surgery. The surgeon charged $210,000 for several codes; reimbursement was pending at 70% of charges. We obtained records and denied 3 of the 5 codes for not being supported by the documentation, resulting in savings of over $96,000.

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Maintaining data integrity for processing claims can be difficult. We provide enrollment and provider data audit services which increase accuracy in enrollment, benefit set up, billing and provider data – making you more efficient and competitive for your clients. We are well equipped and take pride in our ability to work with large sets of data.

Case Study

Nokomis reviewed enrollment records for a client and found an error rate of 18%, primarily due to poor data entry and lack of quality assurance practices. We worked with the client to enhance their employee training program and to establish a robust QA function, which reduced the error rate to less than 1%.

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As industry experts, we offer consulting services that can be adapted to the needs of each individual client. We know billing, coding, reimbursement, and everything in between. We offer coding assistance from our certified coders as well as on-site training regarding coding, billing and reimbursement. From hospitals and clinics to health plans, third party administrators and law firms, we have experience working with more than 120 organizations.

Case Study

Nokomis staff developed dynamic reimbursement models for a medical device manufacturer, which enabled the firm to demonstrate to hospital CFOs the financial savings resulting from the use of their products.

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Out of Network Claims

We offer many solutions for reducing out-of-network claim costs. From claim negotiation to travel networks to reference-based repricing, we strive to obtain the deepest secured discounts on your out of network claims.

Case Study

An out-of-network surgeon charged $49,935 for treatment of a lower leg fracture. Nokomis staff negotiated a case rate of $3,957 on the claim, with provider signoff and agreement to not balance bill the member, resulting in savings of $45,979.