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Are you capturing accurate premium capitated payments and reimbursement?

CMS is continually collecting disparate information from various sources to make entitlement, eligibility and primacy status determinations impacting capitation payments and reimbursements. Pareto Intelligence has developed proven tools, methodologies and predictive models to quickly identify and recover mistaken payments while also improving compliance.

Using our solutions, our clients receive an average 5:1 return on investment, totaling over $100 million in recoveries to date.

$100M+

in recoveries to date for Pareto’s Premium Integrity clients

$30 to $50

average MSP recoveries per member

$80 to $100K

average recoveries per ESRD identified member

$230 to $600

additional premium revenues for partial and full dual eligible members

Learn more about our Dual Eligibles solution

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.

Why Pareto?

Unbiased

We provide a third-party evaluation of internal and/or vendor-led performance.

Compliant

We look both ways to recover underpayments and identify overpayments to mitigate compliance concerns.

Data-Driven

We apply advanced data science and complex business rules to identify premium discrepancies.

See it and Believe it

Our demos say it all. Tell us about your challenges and we’ll show you how we can help you overcome them.

Schedule a Demo