Smarter recoveries. Seamless compliance. Maximum value.

Efficiently identifies and recovers overpayments when another payer should have been primary. Features include proprietary data analytics and primacy scoring, attorney-guided COB determinations, and direct recovery from primary payer.

Results:

• Cost recovery without disrupting pharmacies or members
• Cost avoidance with COB updates that prevent future overpayments
• Seamless integration with all lines of business

Recovers claims paid after member termination, often by rebilling to new coverage. Features include continuous monitoring of terminated policies and eligibility validation, member outreach and flexible payment options, and an online repayment portal.

Results:

• 80% of recoveries are paid by new coverage
• Service-oriented approach for positive member experience
• 2-3x increase in monthly recoveries after transitioning from internal processes

Supports compliance with CMS requirements and optimizes subsidy retention and recovery from overpayments. Features include systemic Part D claim evaluation with algorithms calibrated to align with CMS audit samples, readiness for One-Third Financial Audits, outreach to validate CMS indicators, and Prescription Drug Events (PDEs) audit preparation and recovery.

Results:

• Industry-leading Part D recovery capabilities using established reconciliation processes
• Accurate PDE record and documentation to defend valid payments
• Supports rapid resolution of Corrective Action Plans (CAPs) quickly with proven expertise

Prioritizes most likely overpaid drug claims, identifies claim overpayments, confirms incorrectly billed claims, and recovers overpayments. In addition to claim auditing, we validate clinical appropriateness, billing accuracy, and coding compliance with pre- and post-pay options.

Results:

• Prevents overpayments tied to billing errors and inappropriate drug use
• Recovers 90%+ of overpaid claims
• Automates reviews and reduces false positives, saving time and effort