January 19, 2023
For January 1, 2023, and beyond effective dates, changes have been made to the Premera Extended Payment Integrity Services.
We have rebranded this service from Calypso Post-Payment Extended Recovery to Extended Payment Integrity Services. This was done to better reflect Calypso and the Premera Payment Integrity Division partnership; inclusion of some pre-payment services; and
our partnership with external vendors who manage some components of our extended recovery services.
Extended Payment Integrity Services include:
- Coordination of Benefits (COB) - Investigators and auditors aggressively identify and pursue overpayments due to members’ missing or inaccurate health coverage information.
- Subrogation - Premera partners with an industry-leading subrogation firm to aggressively investigate third-party liability associated with auto insurance, workers’ compensation, personal injury compensation, and more.
- Provider billing errors, hospital bill audit, and credit balance - Pre-payment and post-payment programs utilize advanced data mining and expert investigators to identify billing errors associated with age/service rendered, upcoding,
unbundling of services, incorrect coding, or other aberrant billing.
- New in 2023! Advanced claim editing - This service adds a second line of defense by using software and certified coders to analyze medical claims pre-payment to determine the appropriateness of billed services on a given claim. It
also determines if they relate to other data on that claim or on any historical claims. Our vendor partner offers validation of appropriate modifiers to eliminate the usage of modifiers to bypass first pass editing; claim editing capability across
DME; lab services; biologics; chiropractic; other high-volume claim categories; and more.
Fees for extended recovery services provided on our self-funded contracts are moving to a flat rate of 35% of realized claims savings starting with January 1, 2023, effective dates. Historically, these fees have been between 25-35%.
Self-funded groups with Extended Payment Integrity Services will receive new contract language that reflects the new service name, a new line item for Advanced Claims Editor (second pass editor), and new rates starting with January 1, 2023, effective
dates.