How it Works 

5 Steps to Recovery

1. Selection Criteria. We will ask you to fill out a form that contains approximately 40 questions on how you want your duplicate claims to be identified. For example, some clients require that the Billed Charges on each potential duplicate claim agree with each other in order for it to be considered a true duplicate. Other criteria includes the relationship between the aggregate of the Paid Amount on all potential duplicate lines with the Billed Charges on the original claim.

2.  Sending Us the Data.   We will ask you to send us an extract of your claim and eligibility files. You may use your own proprietary format or we will supply one for you. You may send it to us on tape, CD or we can obtain it by using FTP via our high speed connection.

All of our competitors require you to create an extract file that meets their requirements per their technical specifications.  This often means having to contact your IT liaison and having your request placed on a project queue. 

We realize that your IT staff is already stretched to the limit and may not be able to create an extract file for you in a timely manner.  The solution to this problem is simple.  Anyone with rudimentary knowledge of Microsoft Access* or a popular report writer such as Crystal Reports* can create an output file that we can use to process your claims.

3.  Processing.  After we load the data it will be processed through several levels of duplicate identification. Our standard duplicate checking will find all duplicate procedures for a given Date of Service within Member and Provider. The claim will also be checked under different Provider numbers in order to catch covering providers submitting the same claim as the original rendering provider. Once duplicates are identified, we scour the database for claims that were paid for members that were ineligible on the date of service. All claims that are not found to be duplicates or ineligible for payment are processed to look for NCCI coding errors.

4.  Sampling.  Once the process is complete we will send you a summary of the total duplicates identified and the dollar amounts associated with them.  We will also include a file created to your specification containing a 2% sampling of what the process identified. The sample file is provided for your verification purposes. This will allow you to verify on your system that the claims we identified as duplicates and ineligible have been correctly and accurately selected. 

5.  Results.   If you are satisfied with the accuracy of the sample file and you feel that the totals are worth recovering, we will send the entire file upon payment. Using your own tools you can extract the data, print it or load it into your host system if your software permits automatic claims reprocessing. 

Licensing of software
The propriety software that we have created is also available for license to those managed care organizations that use IBM's AS/400* and iSeries platform. We will provide,  free of charge, any programming required to interface our duplicate processing system to your claims database.  We can also provide software customization to meet the needs of our individual clients. Click the software licensing link for more information.

* Access is a trademark of Microsoft Corporation.  Crystal Reports is a trademark of Crystal Decisions, a Seagate Technology company.  AS/400 and iSeries are a trademark of International Business Machines.

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