Reimbursement models are undergoing radical shifts. Payers on the other hand are trying to adapt to the ever changing government regulations and codes for processing claims. Given the complexity of filing and adjudicating claims, the margin of error is substantially large. Nearly 100 billion dollars are lost every year in overpayments due to fraud waste and abuse and billing and payment errors. Payers need to increasingly focus on payment integrity to remain profitable in the healthcare business.

SCIO® provides advanced predictive analytics that incorporate deep knowledge of industry coding rules, risk adjustment, quality measures and regulations as well as clinical and claims review expertise. Our products allow precise selection and the ability to easily spot weaknesses in payer systems, data flow and processes that contribute to errors.

The following are the key components of our reimbursement optimization programs:

Payment Integrity: Ensuring that claims are paid correctly assists payers in controlling costs associated with fraudulent claims, and reducing overall payment discrepancies, adjudication and reimbursement expenditures. Our medical claims and pharmacy claims auditing services focus on prevention, pre-payment, post-payment. Learn More.

Risk Adjustment: Risk score determines the revenue that payers receive every month. Risk adjustment analytics aligns revenue with expected costs of care and tracks HCC trends so organizations can more easily create suspect lists to support retrospective and prospective collection programs.

  • Risk Adjusted Analytics - Provides actionable information in identifying and managing patient populations and their related RAF scores, thus driving CMS revenue. Risk scores impact the monthly revenue of payers and many providers.
  • CMS Payment Reconciliation - It is vital that each diagnosis is reported accurately for acceptance by CMS. CMS rejected diagnoses need to be identified, corrected and resubmitted as part of risk adjustment. Rejected clinical data and under reporting results in loss of revenue.

Quality Measurement: HEDIS/Stars/P4P Performance Monitoring is crucial for both plans and providers as these quality measures have a significant impact on revenue from payers (including CMS). Learn More.

Our quality measurement capabilities includes:

  • HEDIS Results
  • Stars Results
  • Pay for Performance (P4P) Results

On-demand Webinars



Provider Led Health Plans 202 - A Roadmap to Ensuring Financial and Clinical Sustainability

Held on: September 21, 2017

Watch Video

Leveraging Analytics to drive value-based Reimbursement

Held on: Mon, Oct 17, 2016

Watch Video

Predicting and Preventing Claim FWA with Advanced Profiling & Analytics

Held on: Thu, Sep 15, 2016

Watch Video

Avoid costly overpayments with holistic Payment Integrity programs.

Avoid costly overpayments with holistic Payment Integrity programs