Capturing Savings with a Tiered Payment Integrity Strategy

This case study outlines the collaboration between a large healthcare plan payer and Vālenz Health to review over 626,000 medical claims incurred over six months. The objective was to identify potential savings from billing inaccuracies, coding errors, and clinical discrepancies. Vālenz employed its Clean Claim Verification Solution, utilizing a three-tiered severity-based review model, which included automated claim editing supported by a certified medical coding team. The analysis revealed $539 million in billed charges, reduced to $176 million in allowed charges after adjustments. The study identified potential savings of $112.6 million in initial billed charges, ultimately resulting in $43.4 million in allowed charges. The findings indicated that nearly 75% of coding edits leading to savings were captured in the first two review tiers, emphasizing the effectiveness of targeted reviews in maximizing savings and enhancing payment accuracy. The results suggest that a differentiated approach to payment integrity is essential for addressing various billing issues effectively.