Cost Containment Without the High Cost


Duplicate Claims, payments never recovered for retroactively terminated members and simple coding errors can easily reach into the tens of millions even for a medium sized health plan. Overpayment rates of 5% to 8% of medical expense are common, and for even a small health plan or self insured employer, this can easily exceed several million dollars a year. 

Duplicate claims are paid by health benefit organizations at an alarming rate. Added to this are a growing number of claims paid for but never recovered for retroactively terminated members. Code bundling that doesn't conform to NCCI standards, Medically Unlikely Edits (MUE's) and Global Surgical periods only make matters worse if you are not identifying them up-front. With margins so tight these days you can't afford mistakes - whether system or people-generated. We can help you find those errors by identifying them at the time of entry or after the fact. 


Pilot understands the difficulties related to recovering this money

As much as you would like to think, your claim system is not catching everything. Even the best claim systems interfaced to today's state-of-the-art cost containment software lack a comprehensive mechanism for determining and properly administering industry standard coding errors. And as automated as you believe your claims processing to be, a large percent of claims are manually reviewed and approved - and people do make mistakes.


Pilot works to make it easy for you

Consider that many of the overpayments are ultimately left to the claims examiner to review. The Overpayment and Recovery System by Pilot Information Systems can identify even some of the most difficult scenarios. For instance, we can help you discover how many post surgical office visits were erroneously paid within three months of the global surgical period. We'll help you find both - the current overpayment and the retroactive overpayments.


We have found that most overpayments are paid due to the following reasons:


  • Inadequate Reporting: EDI Claims is the worst offender when it comes to the proliferation of overpayments. Some systems report potential overpayments but the reports are often not reviewed because they are too large and cumbersome to deal with. 

    - and - 
  • Data Entry: While entering on-line, some systems produce warning messages that may not be clear, ignored or simply bypassed in order to maintain claims "productivity". 


Our Overpayment and Recovery System (OaRS) edits claims in real time and batch to mine your database for overpayments utilizing over 25 industry standard edits at a cost far below what our competitors charge.

Psst, want to know a secret?

There are dozens of companies in the cost containment and overpayment identification marketplace. They all try to differentiate themselves by the way they implement their edits, but what most people don’t realize is that industry standard edits are just that – standard. That means that one company does not administer the NCCI edit any differently than the other. The same goes for MUE edits as well as the Add-on Procedures, Global Surgical Days and Multiple Surgical Procedures. In fact, the source of the data used which drives these edits typically come from the same place.

Our service models

We offer our services using two methods. The Software as a Service model, or SaaS, utilizes secure encrypted FTP which allows our clients to send us large batches of claims which are processed all at once. We also offer a Web Service utilizing RESTful technology which processes claims interactively using JSON as the data interchange.  REST has taken over as the defacto standard for SOAP, an unwieldy and complex technology from the 1990's.


Regardless of the methodology you choose, your organization sends claims through our secure connection where the data will be processed and  recommendations returned immediately.







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