Case Study: Nation’s First Health Maintenance Organization achieves $750K+ in overpayment recoveries with SCIO Health Analytics

Nation's First Health Maintenance Organization - Customer Case Study

Nation's First Health Maintenance Organization, an HMO serving over 350,000 children, pregnant women and adults, faced limited provider contracting, a narrow reimbursement methodology concentrated at one children’s hospital, and insufficient internal resources to perform on-site or DRG desk audits. They engaged SCIO Health Analytics to supplement their cost containment efforts and provide deep industry expertise and national audit coverage, leveraging services including HBA (hospital bill auditing), DRG auditing, and the SCIOMine™ platform.

SCIO Health Analytics combined sophisticated payment analytics, data mining, clinical review and experienced nurse auditors with on-site clinical auditing and face-to-face facility exit interviews to identify billing errors and recover overpayments. The engagement yielded measurable results: in 2012 the client completed 103 HBA audits identifying $250,000 in overpayments and 93 DRG audits identifying $500,000, while SCIO also developed internal systems and staffing resources to sustain the audit program.