Case Study: Nursing Facilities Provider achieves $18M+ annual overpayment recovery and major billing-error reduction with SCIO Health Analytics

Nursing Facilities Provider - Customer Case Study

Nursing Facilities Provider faced complex billing across multiple skilled nursing facility (SNF) payment methodologies and lacked the in-house resources and specialized expertise to audit claims nationwide. To address inaccurate billing and payment exposures, the customer engaged SCIO Health Analytics for analytics-driven audit services, including predictive analytics and MDS‑certified nurse reviews of Medicare RUG and intensity‑based per diem claims.

SCIO Health Analytics used predictive models to identify outlier facilities, then conducted targeted, nationwide audits—reviewing medical records based on billed RUG frequency, historical facility error rates, and common billing mistakes. Results showed RUG audit error rates averaging 35% of claims reviewed (with <10% appealed) and per diem errors in 50–60% of audits (6% appealed); SCIO identified about $18 million per year in RUG overpayments, with projections rising to over $30 million at steady state.