Medical Pharmacy & Claims Auditing
SCIO® conducts audits to identify incorrect billing and overpaid facility claims and also offers pharmacy claims auditing services. Our full cycle approach to claims auditing focuses on prevention, pre-payment and post-payment. Whether it is a desk audit or an on-site audit, clients can be rest assured that our sophisticated analytics, operational expertise and clinical knowledge will detect, prevent and recover the maximum number of improper payments.
SCIO’s prepayment auditing solution enhances existing audit concepts by using sophisticated analytics, unmatched clinical expertise, and an efficient centralized platform to rapidly select and review claims well within a payer’s prompt payment window.
This enables payers to avoid - rather than recover - overpayments, streamline payment integrity programs, and generate increased savings on both medical and administrative costs. Prepayment analysis reduces a payer’s reliance on post-pay tactics and is particularly well suited for high dollar/high risk claims, claims from non-participating providers, and to combat quick-hit schemes.
SCIOClarity Chart Validation is a retrospective strategy wherein SCIO’s experienced staff coordinates the retrieval and auditing of member medical records from provider groups to maximize diagnosis code accuracy.
There are five elements to the SCIOClarity Chart Validation service:
1. Suspect List Creation using SCIOClarity Analytics
2. Primary Care Provider Engagement
3. Medical Record Acquisition
4. Chart Review and Coding
The service is used by health plans as a part of their overall efforts to ensure optimal performance in their risk adjustment and quality programs.
SCIOClarity™ Inpatient Data Pursuit
Hospital data pursuit, an important component of a health plan’s risk adjustment program, is the most reliable way to track patients and services rendered. SCIOClarity™ Inpatient Data Pursuit is a full-service hospital data collection service for health plans that eliminates missing and under-reported diagnoses codes related to inpatient stays.
SCIOClarity™ Member Outreach & Provider Collaboration
Health plans and providers can now address gaps in care by collaborating and encouraging data transparency. Our services allow clients to engage providers and members with timely interventions to close the gaps resulting in potential savings and improved health and wellness of their patient populations. SCIOClarity™ Member Outreach & Provider Collaboration is a prospective end-to-end service for closing care gaps.