Case Study: Top 5 National Plan Provider recovers $150M in one year and cuts costs 30–40% with SCIO Health Analytics

Top 5 National Plan Provider - Customer Case Study

Top 5 National Plan Provider, a major Medicare Advantage payer, needed a partner with deep industry expertise and sophisticated analytics to select claims for medical record review in targeted clinical areas, maximize findings while minimizing appeals, and avoid overlap with existing programs. SCIO Health Analytics deployed a dedicated claims-audit team and its SCIOMine™ data‑mining and workflow management technology, integrating with the client’s systems, policies and procedures to focus reviews where they would be most effective.

SCIO Health Analytics identified over $150 million in overpayments across Inpatient DRG, Short Stay, SNF/RUG and Home Health while maintaining accuracy and low overturn rates on appeal; client ROI ranged from 5:1 to 9:1, findings rates were 33–70%, appeals 15–30%, and costs were reduced 30–40%. With minimal client resources required, SCIO implemented ongoing data exchange, targeted contract review of recurring provider issues, and an efficient extension of the client’s cost‑containment team, delivering measurable recovery and new program opportunities.