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Focused Claims Review for health plans

Ensure billing accuracy of professional and facility claims.

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Cost savings found in the details

Focused Claims Review (FCR) is an innovative payment integrity approach targeting procedure, surgery and facility claims. Complex claim errors can only be caught by physician reviewers with the clinical experience to spot mistakes that automated systems can’t detect.

Focused Claims Review Professional

Focused Claims Review Professional targets procedural and surgical claims with the greatest potential yield and a discrete number of providers with atypical billing patterns.  60 to 75 percent of targeted claims reviewed show errors, saving clients 14 to 28 percent of total claims dollars reviewed.1

Incremental

Defined savings not found by automated programs

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Targeted

Minimum claims reviewed for maximum savings yield

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Sustainable

Always refining targets saves long-term costs

Focused Claims Review Facility

Focused Claims Review Facility engages a broad range of clinical and analytical resources to help clients reduce facility claim costs in excess of $100,000 payable.

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Inclusive

Boutique approach allows claim reviews from any clinical category

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Relational

Connects to many hospitals and contracting staff

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Expertise-driven

Deep audit and negotiation experience, plus clinical expertise

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Footnotes

  1. Savings represent cost reductions from the total claims dollars reviewed. Based analyses including pre-sale assessments and OrthoNet performance metrics representing blended average experience across program’s book of business 2006-2018. Average savings based on average weighted spend under management and scope of specialties and procedures reviewed.
  2. Optum analysis – HDCR commercial and Medicare Advantage book of business, 2016-2017. *Individual plan results will vary.