Certilytics’ partnership with Carewise Health uniquely integrates technology, analytics, nurse auditors and case managers to provide a holistic payment integrity solution. Ultimately, our analytics will provide health plans a means to perform “prospective” payment integrity “audits” using the power of the predictive analytics. Our solution spans the point at which we can help a member avoid unnecessary care to the point where the collection of overpayments may be unnecessary.

Health plan customers can now predict and assess risk more accurately and completely to achieve:

  • More valid and consistent audit results and decisions
  • Improved provider network contracting
  • Improved provider relations
  • Increases accuracy of payments
  • More timely audit results to providers
  • Improved identification of potential fraud and abuse

Data Cleansing, Standardization and Enrichment

  • Clean data drastically improves analytics and allows for seamless linking of disparate data sets
  • Use proprietary algorithms verify critical content, such as member IDs, provider numbers, diagnosis codes and procedure codes
  • Gain insight from combining traditional and non-traditional data sets

QEC (Quality, Efficacy, Cost) Analytics

  • Use proprietary, predictive algorithms identify the cases that should be subject to nurse audits or care management
  • Create analytics of provider and member profiles
  • Identify and track high-risk providers
  • Build a road map of improved clinical and financial metrics

Analytics/ ID

Specifically, QEC (Quality, Efficacy, Cost) Analytics, these proprietary, predictive algorithms can be used to achieve various client goals, including:

  • Identify and recover inappropriate claims and overpayments
  • Identify the cases that should be subject to nurse audits or care management
  • Create provider and member profiling
  • Generate a road map to improved clinical and financial metrics
  • Reduce the cost of the payment cycle
  • Avoid and prevent inappropriate claims and overpayments