Improperly paid healthcare claims lead to billions of dollars every year in overspending, but health plans may lack the payment integrity programs needed to address this issue. Where programs are in place, these processes are often still largely manual and require significant internal expertise and resources or are supported by a number of disparate databases or homegrown solutions. All of which can lead to excessive administrative complexity and costs. About $100B or 10% of total U.S. healthcare waste comes from improper claims payouts, and $15B of this is administrative waste from outdated payment integrity solutions.¹
Without a comprehensive payment integrity solution, staff may spend excessive time on inventory management, reporting, claim reviews, and managing vendor overlap and pass order. This is time that could otherwise be freed up to focus on other strategic priorities or to support membership growth. A health plan may also lack the internal resources and expertise, or the ability to add more vendors as needed, to maximize overpayment recovery while reducing the time and costs incurred to recover these payments.
Hobson & Company, a research firm specializing in Return on Investment (ROI) studies, partnered with ClarisHealth to investigate these challenges. Through eight in-depth interviews with existing ClarisHealth clients, they explored the value generated by the Pareo® solution. Clients found that ClarisHealth addressed their challenges and delivered measurable results. This white paper aims to showcase examples of the operational and business benefits that can be achieved with a comprehensive payment integrity solution.
Based on this analysis, a sample organization with: 16,500 claims reviewed per month; an average of $25M in claim overpayments recovered per year; and paying $5M in contingency fees annually to vendors, could see an ROI of 265% and total value creation of $8.6M over three years with Pareo®.