in recoveries to date for Pareto’s Premium Integrity clients
average MSP recoveries per member
average recoveries per ESRD identified member
additional premium revenues for partial and full dual eligible members
Identify & Recover Mistaken Premium Payments
Success today depends on a comprehensive evaluation of MA premium reconciliation, inclusive of all adjustment reasons, and establishing processes and partnerships to reconcile data at the appropriate frequency (typically monthly).
Pareto Intelligence’s Premium Integrity solution helps payers navigate Medicare Secondary Payer (MSP), Dual Eligibility, End Stage Renal Disease (ESRD) and other reporting complexities between CMS and payers to recoup underpaid capitation payments and reimbursement, as well as mitigate compliance risk. We leverage clinical (e.g., claims, medical procedures, sequence of diagnosis and procedures, medications) and non-clinical (e.g., demographics, enrollment, location of care) data to identify and predict status with up to 95% accuracy. Then our skilled outreach experts facilitate ECRS updates for MSP, reconciliation with providers for ESRD and Dual Eligibility enrollment/recertification.
Significant Opportunity for Health Plans
- Capture Six-Year Lookback: Health plans can reconcile most premium mispayments for the current year and up to six years prior.
- Increase Revenue: Properly classified member statuses can lead to significant capitation payment adjustments.
- Mitigate Compliance Risk: Correctly documenting Medicare Secondary Payer versus Primary assures plans remain compliant with CMS.
- Achieve Ongoing Revenue Accuracy: Monthly monitoring ensures complete and accurate premium revenues year round, as well as sustained compliance with CMS guidelines.
We provide a third-party evaluation of internal and/or vendor-led performance.
We look both ways to recover underpayments and identify overpayments to mitigate compliance concerns.
We apply advanced data science and complex business rules to identify premium discrepancies.