Revenue & Payment Integrity Solutions
Risk Documentation Improvement
Complete risk documentation is critical for financial success in any risk adjusted market. Pareto’s Risk Documentation Improvement solution applies market-specific suspecting algorithms to identify and prioritize undocumented risk gaps for remediation through prospective and retrospective campaigns. Our suspecting models also leverage social determinants of health data to improve predictability, identify instances of natural gap closure, and generate more effective and targeted chart chase lists.
This solution evaluates in both directions, including both undocumented and potentially mis-documented risk, to achieve complete and compliant risk scores. We also objectively evaluate performance across program and campaign effectiveness as well as the performance of providers, conditions, and members to inform ongoing strategy and improve outcomes.
From encounter through to regulatory submission, both health plans and providers are responsible for preventing data degradation. Pareto’s Data Integrity solution evaluates this encounter submission process to pinpoint the data quality issues impacting revenue and compliance. Our solution works by applying advanced analytic models and root cause clustering algorithms to identify where data quality issues occur and prioritize remediation based on materiality.
Pareto’s process is built to recover lost data, improve processes by reducing errors, and identify instances of incorrectly captured and submitted encounter information that pose a compliance risk. This holistic and independent approach to Data Integrity helps clients achieve complete and accurate encounter submissions.
Ensuring ongoing claims payment accuracy through effective coordination with Medicare benefits is a complex process. Pareto’s Payment Integrity solution modernizes the collection of critical Medicare Secondary Payer (MSP) information from employer groups, streamlines Section 111 reporting, and uncovers inaccurately paid claims for remediation.
This solution maximizes recovery of overpaid claims, uncovers underpaid claims that present compliance risk, and reduces future mistaken payments by addressing the root cause of these issues. Our services include electronically collecting employer information, Section 111 mandatory insurer reporting, and coordination of benefits (COB).
Provider Revenue Accuracy
Traditional revenue cycle management activities focused solely on billing and collections are no longer sufficient in delegated risk models. Pareto’s Revenue Accuracy solution enables providers in value-based or risk-bearing contracts to review, analyze, oversee, and improve key processes that drive revenue performance to ensure accurate capitation payments from private payers, CMS and/or state governments.
This solution packages elements of many of our solutions listed above—including our Risk Documentation Improvement, Data Integrity and Premium Integrity solutions—to uncover financial improvement opportunities for providers operating in risk-based models. Our holistic approach to revenue accuracy creates a new perspective on revenue cycle management and ensures that all parties are fulfilling their operational requirements to improve provider revenue.