成本控制 & 护理质量

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For your state agency and managed care organizations to run at peak efficiency with minimal waste, 你需要三个基本的东西. 利益协调 (COB) ensures that you pay only claims that you are responsible for. 付款完整性(PI), 也被称为项目完整性, 确保欺诈, 废物和滥用(FWA)受到严格控制, and that claims are medically necessary and correctly submitted. Care quality ensures strategies and services are in place to improve care and reduce costs for members with the highest degree of need.

Gainwell has the experience and the solutions you need to keep your programs running efficiently, 不影响您的收件人的护理质量.

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足球外围平台如何提供帮助

足球外围平台在1985年率先开展了利益协调, when we saw that Medicaid was paying billions of dollars that it shouldn’t. 今天, 医疗补助的COB全球十大外围足球平台, 医疗保险, 军事, 国家机构的项目和mco是最好的, 最具创新性. No one else can come close to our proprietary data and algorithms.

Our PI solutions root out claims that are erroneous for any reason, at any stage in the claim cycle. 足球外围平台在付款之前或之后识别不正确的索赔. If post-payment, we have robust recovery systems in place to get the money back into your account. We can even spot bad claims without medical records from the provider, 减少磨损,加速恢复. Machine learning and artificial intelligence (AI) are continually making our solutions smarter and more automated, 但当需要人的帮助时, 足球外围平台的员工是业内最优秀、最有经验的.

足球外围平台先进的护理管理生态系统将个性化, 数据驱动和可操作的护理计划在您的指尖, reducing inefficiencies and empowering your teams to focus on what’s important – caring for those who need it most.

利益协调

预付款的全球十大外围足球平台

成本规避胜过付费追逐. 足球外围平台的端到端COB全球十大外围足球平台专注于交付速度, 以及数据质量和准确性,以创造可操作的见解. This, combined with our unique market expertise, ensures maximum cost avoidance for your plan.

复苏后付费

已经支付了索赔? 没有问题. We examine improperly paid claims using artificial intelligence and machine learning to select the best candidates for recovery. Then we pursue those recoveries using efficient electronic processes to maximize savings.

病例管理

足球外围平台的案例管理全球十大外围足球平台是有意义的分散, 杂乱的数据, 并将案件推向赔偿和结案. 足球外围平台提供安全的服务, 可靠的, 全天候的网络访问, 实时更新, 文档成像和指导工作流程. Our case managers and attorneys are unmatched when it comes to complex, high-dollar cases.

付款的完整性

临床索赔审查

足球外围平台的临床索赔审查确定编码, 位置, level of service and reimbursement errors by comparing claims against medical records, 要么提前付款,要么后付款. Driven by synergy between artificial intelligence and clinical experts, our battle-tested and constantly improving algorithms target claims most likely to have errors.

付款方式分析

付款方式分析 is a customizable post-payment data mining solution that uses exclusive data analysis to compare claims history against specific billing, 编码, utilization and reimbursement rules that client systems or claim processors might miss.

FraudCapture®

FraudCapture是模块化的, cloud-hosted platform that provides end-to-end support in the identification of fraud, 浪费和滥用. 适用于各种规模的企业, 足球外围平台的直觉, mobile-friendly software exposes issues through clear data visualization and easy-to-use data exploration tools.

药房支付诚信

Our 药房支付诚信 solution uses AI-driven analytics to target high-value cases for review. 对特定的政策和法规进行定制是很容易的, and clinical reviews are performed by staff pharmacists and nationally certified pharmacy technicians.

资格认证

更好的成本预防也意味着更好的合规. Many employers and states are accruing high financial costs from those who don't meet their eligibility criteria, 比以往任何时候都更需要验证资格. Our 资格认证 solution handles verifications with sensitivity, ensuring employees understand exactly why someone may be ineligible, 并解释每一步的过程.

利用管理

利用管理 addresses the most pressing needs of state Medicaid programs by combining cost management with accurate pre- and post-payment claim reviews and prior authorization from our Clinical Care Reviews.

护理管理

Our interoperable 护理管理 platform is built on a solid foundation of automation, 标准化和成熟的流程. 利用已证实的数据, industry-standard COTS products such as the Johns Hopkins ACG System and administrative and clinical information, 足球外围平台的服务提高了质量,降低了护理的总成本.

足球外围平台可以帮忙. 但下一步是你的了!

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额外的见解

TRICARE and Medicaid 利益协调: The System is Broken
通过调整付款人产生预付款索赔审查节省 & 供应商激励机制
预付诚信如何激励循证护理