Contract Compliance Audit Services

The Issue
In their effort to stem escalating healthcare costs, insurance companies and employers often overlook the billing and reimbursement errors due to misapplied or misinterpreted contract terms for various ancillary services. These errors can often be significant and require the specific contract audit expertise to understand the root cause of the problem and recommended solution.

The Solution
Contract Compliance Audit Services (CCA) is an intensive audit review service that looks at specialty pharmacy, paid home infusion, durable medical equipment and renal (dialysis) claims. CCA identifies the overdelivery of products, services or overpayments due to misapplied or misinterpreted contract terms. CCA reconciles claims not only based on the correct contractual reimbursement, but often, savings are realized by our ability to verify and reconcile the actual physician order, versus what was billed on the claim.

Value Points

• Specialized cost containment for unregulated high-cost specialty services with high potential for savings
• Productive post-payment tool for controlling Home Infustion/DME costs which are typically under-scrutinized
• Additional filter to maximize post-payment savings recovery in addition to traditional hospital bill audit or DRG validation services
• CCA results can be used to improve and strengthen future specialty contracts with providers

How It Works
Contract Compliance Audit Services focuses on specialty services where billing and reimbursement error rates are high due to misapplied or misinterpreted contract terms. These include Home Infusion, Durable Medical Equipment, Renal Dialysis and high cost injectable medications administered in the physician or outpatient care setting. Viant's CCA Services are performed by experienced pharmacists, nurses and contract audit professionals who understand the complexities of claims systems, reimbursement methodologies and clinical service issues. Once identified, savings can be recovered through refund recovery and/or offset.

Advantages

• Savings average 45%, and vary depending on service mix, reimbursement terms and other payer criteria
• Average dollar savings equates to approximately $1200 per claim
• Scalability: Viant reviews over $1 billion in specialty claims annually
• Ability to reconcile complex J-code vs. NDC unit, package size and pricing discrepancies
• All CCA reviews are customized specific to the client’s contract language and reimbursement methodology
• Viant’s CCA Team consists of pharmacists, nurses, and other healthcare professionals who provide a strong clinical background in the appropriate specialty being reviewed

Summary
In addition to recovering significant savings for payers, Viant’s CCA results offer organizations a comprehensive and detailed understanding of the "root cause" of overpayments and much of our audit work results in a client being able to address internal problems and develop significant process improvements of their own. Although our process and audit work varies from project to project, we offer a "roll-up the sleeves" approach in reconciling the complete accuracy of a claim’s payment on these important specialty claims.

To learn more about Viant’s Contract Compliance Audit services, call us today at 800.820.5824.