Performant
Reshaping Payment Integrity Audit With Technology

The payer (insurance provider) is always considered to be in the catbird seat in the U.S. healthcare system. However, this vital player is not free of the challenges that have long plagued the healthcare landscape. Contrary to common expectations, the lack of transparency surrounding healthcare costs is a pressing issue for payers, as much as for patients and clinicians. Coding errors such as upcoding, miscoding, and duplicate billing have a detrimental impact on payers, leading to significant loss due to fraud, waste, or abuse. These losses are substantial and have been estimated to total tens to hundreds of billions of dollars each year, driving increases in health insurance costs for everyone. In addition, as the number of telehealth services increased during the COVID-19 public health emergency, so did concerns that such expansion may result in an increase in fraudulent claims. To this end, payers are seeking the expertise of reliable payment integrity solution providers that can help them efficiently identify erroneous, incomplete, suspicious, or inaccurate claims submitted by providers. This is where California-based Performant comes into the picture.

As a healthcare cost containment company, Performant screens healthcare claims against several criteria, including coding procedures and medical necessity standards, to determine whether a claim should be further reviewed for potential adjustment and overpayment recoupment. Focused on performance differentiation, Performant delivers a purpose-built technology—Performant Insight™—that helps customers predict leads, rapidly assess billing patterns and abuse, and improve access to their data. “With Performant Insight, we aim to drive value for our payer clients and help them strike the right balance between working in partnership with service providers and providing the oversight necessary to ensure healthcare costs are contained, transparent, and appropriate,” says Simeon Kohl, Senior Vice President and General Manager of Healthcare at Performant. Performant leverages its technology to focus on two areas—claims-based offerings and eligibility-based offerings—with national-level contracts with the Centers for Medicare & Medicaid Services (CMS) and most of the largest U.S. payers.
Performant’s unique algorithm and scoring technology helps payers balance provider abrasion and identify claims that are eligible for audit and recoupment. From the get-go, Performant’s platform brings an incredible level of sophistication while analyzing claims. “We are trying to bring the same level of sophistication into an AI engine that can collect all the data from our prior experiences and audits, feed the data back into the system, and allow the system to analyze and flag claims with a high probability of being improperly billed,” notes Kohl. Moreover, when working with national payers operating numerous claims platforms across varied geographies, it can be critical to bring together multiple payment systems to have a holistic view of the spend.

Performant’s technology was built from the ground up toconsolidate and manage disparate, complex healthcare data and identify claims with a high probability of error. From an eligibility perspective, Performant Insight™ offers broad capabilities to assess massive volumes of data and identify if claims with similar names and addresses are truly for the same person.

Performant’s capabilities were in full display while assisting one of the nation’s largest health plans that was growing frustrated with its incumbent vendor for TPL Identification and reclamation services. The vendor had grown slow and inflexible in responding to client needs and was unaccountable in reporting. After a year of scouring the market for a potential vendor alternative, the health plan approached Performant. Leveraging Performant Insight™, TPL reclamation billing was initiated within two months and achieved results up to 50 percent higher than those of the incumbent vendor. Based on the realized success, the health plan increased Performant’s scope, eventually replacing the legacy vendor entirely within the first one and half years. During the next two years, the health plan engaged Performant in a portfolio of other services, including recovery of aged provider debt, coordination of benefits (COB) data mining, COB cost avoidance, and clinical audit services. To execute each service on a national level, Performant has onboarded data from the client’s multiple claim systems and quickly implemented analytic services uniquely tailored to each solution, line of business, and claims platform.

While payment integrity programs have undergone major changes over the last 24 months, Performant aligned its services with the current trends, building algorithms to review claims for emerging services. Performant continues to operate as a customer centric company with an agile approach to truly understanding the customer’s needs. “Our highly adaptable technology, geared toward the needs of payers of all sizes, combined with multiple investments in subject matter experts, sets us apart from our competitors,” says Kohl.

Having made significant investments in technology, data experts, clinical experts, nurses, and coders, Performant boasts of a diverse team that covers all types of healthcare spending. The company houses an incredibly talented technology team that is responsible for managing the technology stack and supporting Performant with all client-facing engagements. “We have been really lucky in the last couple of years, bringing in experts that have managed payment integrity programs for some of the largest national payers. Their experience has helped us prioritize our investments to address the pain points that our competitors fail to undertake,” comments Kohl.

Operating in an underserved space, Performant strives to fill the gap between payment integrity vendors and technology organizations. With the right human capital, expertise, valuable data sets, and a unique proprietary technology under its belt, the company has been driving meaningful innovation and investment in the payment integrity space and aims to continue doing so in the future.