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.