In this episode, Michael introduces Dawn Cornelis, the co-founder and Chief Transparency Officer of ClaimInformatics. ClaimInformatics is a payment integrity solution that helps its clients identify improper healthcare claim payments and recoup the money for the employer.
When Dawn entered the world of claim processing 30 years ago, it didn’t take long for her to see that money was being wasted on a massive scale via unnecessary procedures, upcoding, bad systems, and egregious contracts. Unfortunately, there’s more abuse now than ever. With 3-7% of healthcare claims being inaccurately paid, it’s grown to be a problem that is worth over a trillion dollars. This inspired her to co-found ClaimInformatics to catch errors, fraud and contain costs for members. She emphasizes that these costs aren’t savings, it’s money that shouldn’t have been paid in the first place.
ClaimInformatics has a process where they are able to identify six levels of errors that lead to overpayments, including upcoding, miscoding and outright fraud. They review ASO/TPA network agreements, acquire and review all data, re-adjudicate claims, then share the results with clients to illustrate the level of overpayment in their plan. From there, they initiate the recovery process where they typically recover 80% of improper payments on behalf of the employer. In addition to recouping money for the employer, they put providers on notice who are engaging in egregious billing practices that they are now being watched and will be reported to the Network and Medical Board if behavior continues.
ClaimInformatics works primarily with clients who are self-funded and under ERISA guidelines. They have flexible fee structures with aligned incentives to generate results for their clients. Dawn recommends everyone take a hard look at their reports, review their ASO agreement, and become acquainted with their performance audit terms. ClaimInformatics stands for integrity and member-centric service, and we’re excited to see how they continue on this trajectory into the future.
Here’s a glance at what we discuss in this episode:
- 00:30 – Introducing Dawn, the co-founder and Chief Transparency Officer of ClaimInformatics.
- 02:30 – 30 years ago, she got into the claim processing and became a System Configuration Specialist; she then became a plan administrator for a Fortune500 commercial group.
- 05:35 – They read the story in the data, and the data isn’t good in terms of waste via unnecessary procedures, expensive services, bad systems, and egregious contracts.
- 07:45 – ClaimInformatics is all about integrity; they ensure payments are accurate and in accordance with agreements made.
- 08:30 – They catch errors and fraud to contain cost; it’s not savings, it’s money that shouldn’t have been paid in the first place.
- 10:55 – Why are we still seeing 2-3% leakage when that waste is 100% preventable?
- 11:15 – Most of their clients are self-funded and under ERISA guidelines.
- 11:30 – The ClaimInformatics process: They review ASO, ascertain and review all data, re-adjudicate claims, then take the results to show clients what they’ve captured.
- 12:50 – They follow the same guidelines as a claim’s office, make deposits on behalf of clients, and are member-centric in terms of protecting their overpayments, too.
- 14:05 – They ensure member liability is made whole; they go back three years and see lots of coding and billing errors that are non-compliant of the rule sets.
- 17:15 – Historical claims review results: Incorrect codes and upcoding make groups and members pay more.
- 19:30 – Medical records either support or don’t support the coding choice; they have seen upcoding happen frequently across the board with outside billing companies.
- 21:10 – There’s more abuse today than ever; there are six levels of errors that they’ve identified.
- 25:22 – Providers are paid based on the severity of illness of a patient; adding diagnoses and up-coding increases payment.
- 27:05 – Deliverables: Clients have full access to the ClaimInformatics portal, they identify, track and seek causation to create a solution at the root level.
- 28:50 – The provider response: ClaimInformatics gives extreme detail to the provider so they can make a change to their behavior and the way they’re operating.
- 31:20 – They make it so that any overpayments can turn into a credit.
- 33:05 – They contact providers to let them know that their data is under scrutiny; groups don’t typically get their money back on large fraud cases.
- 35:10 – 3-7% of healthcare claims are inaccurately paid; they have an 80% recovery rate.
- 39:45 – Their fee structure: Risk-free at a contingency rate; they don’t want to add to the cost; they can do per member per month as well.
- 41:05 – Employer fiduciary responsibility: They created a safe harbor program to fill fiduciary responsibility.
- 43:45 – A primary takeaway: Employers can start asking for reports from administrators to see what they are doing to capture things on the front and back end.
- 45:00 – Review your ASO/TPA agreement and performance audit terms.
- 46:35 – They’re excited about the legislation out there that is forcing the hand of big organizations; they’re here to support in the right way.
- 47:00 – It’s a $3.7 trillion dollar problem that includes having trouble accessing data that ends up speaking for itself.