Claims Audits and Identification of Revenue Recovery Opportunities

To remain financially sound in today's health care environment, accurate claims payment and maximization of revenue recovery opportunities are critical. pmpm® works with your management, supervisory, and line staff to establish claims payment processes and identify opportunities. We work with clients to establish a revenue recovery process within the Finance Department. Working closely with an in-house team, we will assess your current operations, conduct a detailed claims audit, provide findings reports that quantify the opportunities to enhance financial performance, and work with clients to implement specific recommendations. In most cases, clients are able to document the percentage increase in revenue recovery within the first year.

In addition, pmpm® oversees the development of a detailed Recovery and Eligibility Policies and Procedures Manual. The manual includes step-by-step detail addressing all functions necessary to make a revenue recovery process successful: claims audits, coordination of benefits, third party liability, electronic eligibility reconciliation, eligibility guarantee, identification of inappropriately paid claims, shared risk distribution, and stop loss targets.