We support you throughout the entire claims payment cycle with seamlessly integrated services.
We provide comprehensive, customized medical claim review services to third party administrators and payors. Our highly experienced and knowledgeable team of healthcare coders, claims analysts and medical professionals understand the risk areas inherent in medical claims. Our claim review process can handle both retrospective and concurrent claim reviews.
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 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 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
With our claim review services savings are gained from:
- Charges not being supported by documentation
- Incorrect coding, units, and code combinations
- Incorrect fee schedules applied
- In-network claims incorrectly processed as out-of-network and vice versa
- Members not being eligible for services
- Administrative errors on the claim: no authorization for services rendered, services not covered under the certificate of coverage
- Out of network claim negotiation and application of travel networks
- Fraudulent claims
- Duplicate claims
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.
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.
Nokomis Health reviewed enrollment records for a client and found an error rate of approximately 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%.
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 third party administrators, law firms, and internet based companies, we have experience working with more than 70 organizations.
Nokomis Health 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.
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.
An out-of-network surgeon charged $49,935 for treatment of a lower leg fracture. Nokomis Health 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.