Software Solution for Health Benefits Industry:

Revolutionizing Cost Containment with Efficiency

Cost Containment Without the High Cost

Duplicate Claims, payments never recovered for retroactively terminated members and simple coding errors can easily reach into the tens of millions even for a medium sized health plan. Overpayment rates of 5% to 8% of medical expense are common, and for even a small health plan or self insured employer, this can easily exceed several million dollars a year.

Duplicate claims are paid by health benefit organizations at an alarming rate. Added to this are a growing number of claims paid for but never recovered for retroactively terminated members. Code bundling that doesn’t conform to NCCI standards, Medically Unlikely Edits (MUE’s) and Global Surgical periods only make matters worse if you are not identifying them up-front. With margins so tight these days you can’t afford mistakes – whether system or people-generated. We can help you find those errors by identifying them at the time of entry or after the fact.

Cost Containment Insights

Unveiling Overpayment Causes

Inadequate Reporting

EDI Claims is the worst offender when it comes to the proliferation of overpayments. Some systems report potential overpayments but the reports are often not reviewed because they are too large and cumbersome to deal with.

Data Entry

While entering on-line, some systems produce warning messages that may not be clear, ignored or simply bypassed in order to maintain claims “productivity”.

Our Overpayment and Recovery System (OaRS) edits claims by mining your database for overpayments utilizing over 25 industry standard edits at a cost far below what our competitors charge.

Unlocking Secrets

Cost Containment and Overpayment Identification Marketplace

There are dozens of companies in the cost containment and overpayment identification marketplace. They all try to differentiate themselves by the way they implement their edits, but what most people don’t realize is that industry standard edits are just that – standard. That means that one company does not administer the NCCI edit any differently than the other. The same goes for MUE edits as well as Add-on Procedures, Global Surgical Days and Multiple Payment Procedure Reduction (MPPR). In fact, the source of the data used to drive these edits typically come from the same place.

Our service models

We offer our services using two methods. The Software as a Service model, or SaaS, utilizes a secure VPN connection to our SSAE 18 Type II (SOC2) certified server which permits our clients to send us large batches of claims to be processed all at once or in separate files throughout the day. We also license our software for those claim shops running their business on the IBM i platform.

Traditionally, identifying overpayments has been a costly and limited endeavor. Pilot Information Systems disrupts this paradigm, offering a more efficient, affordable and automated solution that eliminates these barriers.

We stand firm in our commitment to fairness and transparency. With us, there are no binding long-term agreements or devious “evergreen” clauses. We offer month-to-month agreements, underlining our belief in earning your trust every day—an underpinning that’s helped us maintain longstanding relationships with our clients for years.

A lot of our competitors charge their customers based on a percentage of savings, which we find shameful because it costs them the same to identify a $10 error ($3 identification fee) as it does a $1,500 error ($450 identification fee). Pilot believes that you should pay one flat fee for all of your cost containment needs.

As part of our unique sales process, we offer a no cost claims analysis to identify potential recoveries lingerining within your claim database. This includes a detailed account of potential recoupment alongside a sampling of our findings, empowering prospective clients to verify the accuracy of our work and whether it’s worth their effort to proceed forward.

Whether you’re seeking a primary cost containment system or a complementary solution to spot overpayments missed by your current system, Pilot is the ideal choice. With us, you get superior claim editing services, significant cost savings, and unrivaled automation. Welcome to Pilot Information Systems—where innovation meets savings.