Data Mining Detects & Prevents Improper Payments

May 30, 2024


CERIS supports our partners in ensuring health claims are paid accurately.  We are uncovering more ways for clients to save by finding overpaid claims and recovering those dollars. CERIS eliminates frustration by identifying which claims to review, quickly and effectively reviewing with our analysts, and providing a full recovery service for post-payment reviews.

Our audit selection criteria apply contract terms, reimbursement policies, industry and member guidelines to identify overpayment opportunities caused by billing errors, system limitations, processing errors to name a few. We will consult with our clients on root causes to prevent further improper payments.

See CERIS case examples below demonstrating significant improvements in detecting and preventing improper payments through data mining.

Data Mining Sample Findings 1:

  • CERIS client has a policy stating ancillary items such as supplies and equipment are included in the payment of the primary service.
  • Client’s providers are billing ancillary items individually that should have been billed together, thus causing overpayments to the providers.
  • CERIS identified the errors and helped the client recover approximately $1.3 million on 450 claims.

Data Mining Sample Findings 2

  • CERIS client contracting and member plan documents support only reimbursing inpatient provider bills and should not pay outpatient bills falling within the inpatient admission.
  • Client’s providers are billing outpatient services separately while a member is inpatient, creating overpayments to the providers.
  • CERIS identified errors and helped clients recover approximately $1 million on 400 claims.

Data Mining Sample Findings 3:

  • CMS policies state that pre-operative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty are included in the reimbursement for the surgical procedure performed.
  • Client’s providers are billing professional services separately from the global surgical procedure that was performed, creating overpayments to the providers.
  • CERIS identified errors and helped clients recover approximately $800K on 8,000 claims.

Let's partner to a clear path to greater accuracy and cost savings.

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