The PAIR Report:
a Two-Phase Solution
Our PAIR (Payment Accuracy, Integrity, and Risk) Report is a comprehensive review of your plan’s spending, designed to ensure accuracy and identify potential savings. We categorize findings into three tiers based on severity and actionability.
The PAIR Report is an in-depth forensic analysis designed to help self-funded health plans identify overpayments, potential fraud, and areas for cost recovery.
Our comprehensive approach ensures your plan’s fiduciary
responsibilities are met, while uncovering significant savings opportunities.
Phase I: Analysis
Our initial analysis provides a detailed examination of your plan’s spending, highlighting:
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Overpayment Identification: Pinpointing claims where the plan overpaid.
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Administrative Services Review: Scrutinizing the transparency and fairness of your ASO/ASA agreements.
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Error Detection: Identifying improper billing practices such as unbundling, upcoding, and duplicate payments.
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CAA Compliance: Ensuring adherence to the Consolidated Appropriations Act requirements.
Key Findings & Solutions
The PAIR Report categorizes findings into three tiers based on severity and actionability:
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Tier I Findings: Direct overpayments that can be recovered immediately.
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Tier II Findings: High-probability errors requiring further verification.
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Tier III Findings: Unusual claims that warrant additional scrutiny.
Sample Detailed Analysis:
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Total Claims Analyzed: $652.9 Million
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Potential Overpayments: Up to 19.2% of claims
Example Findings:
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Improper Coding: E.g., Billing for more complex procedures than were performed.
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Duplicate Payments: E.g., Multiple payments for the same service.
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Non-compliance with Network Policies: E.g., Claims paid without applying negotiated discounts.
Phase II: Corrective Action
Based on our findings, we implement immediate corrective actions to drive cost savings and ensure compliance.
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Overpayment Recovery: Initiating the process to recover funds from providers and networks.
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Pre-payment Prevention: Setting up systems to prevent future overpayments.
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Ongoing Monitoring: Continuous oversight to maintain compliance and efficiency.
This phase is crucial for ongoing cost management and compliance, ensuring that your plan operates efficiently and transparently.
Compliance & Fiduciary Protections:
Adherence to the Consolidated Appropriations Act (CAA)
The CAA mandates several key requirements for self-funded plans to enhance transparency and accountability in healthcare spending. Our services help to ensure compliance with these provisions:
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Prohibit Gag Clauses: Ensure transparency in pricing and provider information.
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Improve Cost Transparency: Provide clear and accessible information about the cost of services and coverage.
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Disclosure of Compensation: The CAA mandates the disclosure of direct and indirect compensation from service providers if it exceeds $1,000.
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Administrative Service Agreement Compliance to determine eligible fees are fair and reasonable.
Fiduciary Protections Under ERISA
As a fiduciary of a self-funded health plan, adhering to ERISA mandates is crucial. Our services help you fulfill these responsibilities:
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Prudent Management: Ensure plan assets are managed prudently and claims are paid accurately.
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Diversification: Avoid excessive risk by ensuring claims are appropriately diversified and managed.
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Adherence to Plan Documents: Ensure all actions conform to the plan's governing documents, provided they are consistent with ERISA.
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Fee Reasonableness: Monitor and ensure service provider fees are reasonable and justified.
Customizable Review Options
Our services are fully customizable to meet the specific needs of your plan:
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TPA/Network fee assessment
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In-Network and Out-of-Network Claims Review
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Edit Ignore Lists
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Exclusion Lists for specific providers or services
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Medicare repricing
Unlock the Secrets in your Data
By leveraging our Safe Harbor Program, you can ensure your health plan operates with maximum efficiency, compliance, and cost-effectiveness, fulfilling your fiduciary duties under ERISA and adhering to the CAA requirements. Transparency is here, and we help you use it to your advantage to drive down costs while holding parties accountable.