Shift discovered a provider who was billing antigen therapy incorrectly and leveraged CMS Comprehensive Error Rate Testing (CERT) data to identify services with high improper payment rates. Evidence was then found that the provider was an outlier for a specific antigen service. Shift's customer was then able to identify over half a million dollars in potential recoveries and the health plan was able to educate its providers on correct billing codes, driving future savings across the organization.
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Manage Cookies"For one health plan, Shift found an allergist who was a statistical outlier compared to his peers specifically for billing antigen therapy. When a provider is an outlier only for a particular service, it is indicative that they are probably billing that treatment wrong. In addition to this, Shift leveraged the comprehensive error rate testing data set, also known as to flag codes that have high error rates. Oftentimes, Shift has found that when a provider is an outlier for a specific service, that service is also known by CMS to have a high error rate. These two pieces of evidence supported the fact that the provider was billing this treatment incorrectly. In this case, Shift was able to find over half a million dollars for the health plan and the health plan was able to work with a provider to educate them on how to build this code properly. In addition, they were able to educate all of their providers on how to build the code properly, having potential savings across the entire organization."
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