100% of employers lose 20%
Understanding Healthcare Waste and Recovery
Recovery
The key to successful and consistent recovery is through a reliable process. Each error brought to the attention of the TPA must be irrefutable. This high standard allows for up to 60% of the errors to be identified and corrected.
With our first fully automated product, Clērblū Insight is able to identify a third to half of the irrefutable waste. This is consistent with our expectations and our software will grow and refine.
Correctable Waste
Duplicate Billings - A bill is resubmitted after no action by the payer and both are paid.
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Improper Patient or Provider IDs - The IDs may be wrong, expired, or missing but the claim is paid when it should be rejected.
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Incorrect Coding - Incorrect or inappropriate use of medical codes (e.g., CPT, HCPCS, or ICD10) for claims as a result of upcoding, unbundling, or mismatched codes.
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Contract Deviation - Paying higher rates than the contracted rate for a specific service.
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Unbundling - Separating a single medical procedure or service into multiple components and billing each component separately, resulting in higher total charges.
Medical Unlikely Edits - Claims for services that exceed the typical number of units for a specific procedure or service, deemed unlikely to be medically necessary for a single patient on a single day.
Episode of Care Logic - Identifying inconsistencies in the comprehensive set of medical services provided to a patient for a specific health condition or medical event over a defined period.
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Systemic and Contractual Waste
Other waste is identifiable but not recoverable. Due to the sheer size and scope of contracts, they are signed with the belief that the employer’s best interests are front and center. ClÄ“rBlÅ« is able to identify “fiduciary bombs,” where pricing exceeds industry norms yet the rate has been agreed to in the contract. While these payments are not improper or appealable they are addressable through contract adjustments.​
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Recovery for the Employer
Traditional Payment Integrity firms find waste in computer-aided episodic reviews that rely heavily on manual identification. This process looks at select data with a historical lens. Recovery for the client either is settlement-driven, requiring a contentious legal process or provider-based, which is labor-intensive pursuing the hundreds of providers.
ClērBlū is different by design. We examine all claims data in real-time and identify mistakes during the open payment window. In a blame-free process, we work with the TPA to correct the errors, achieving the maximum credit or refund for the employer.
Impact
Average Monthly Numbers Per Employee (2024):
Employer spend (Healthcare only) $1166/month
Loss per employee $200/month