Administrative Compliance Support

Recovery Audit Solutions, Inc. (RASI) performs a payment integrity analysis of prepaid and postpaid claims data to determine if services were provided based on contractual, policy and procedural standards. RASI’s experienced staff utilize cutting-edge tools and technology to deliver accurate audit results and identify process improvement recommendations for our clients.
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Eligibility Determination

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Contract Compliance

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Complex Payment Terms

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Monthly Membership Report (MMR) Validation

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Non-Covered Benefits

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Duplicate Payments

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Coordination of Benefits

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Third Party Liability

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Subrogation

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Credit Balance

 Case Study

Monthly Membership Report (MMR) Validation

– Case Description

Medicare Advantage (MA) plans are responsible for reconciling CMS Monthly Membership Reports (MMR). A small Medicare Advantage health plan sought a vendor to validate CMS MMR payments for their Medicare Advantage members.

Summary

Recovery Audit Solutions, Inc. (RASI), was the vendor of choice to perform a review and reconciliation on behalf of the plan. RASI’s experienced staff combined with RASI’s cutting edge technology identified weaknesses in the plan’s processes and uncovered significant findings allowing the plan to obtain reimbursement of missing dollars and significant cost savings for future dollars.

Benefit

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$1 million dollars recovered within 4 months

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Improved internal processes

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Increased future revenue

Final Result

The plan was able to adapt RASI’s processes to improve internal measures, implement an internal monthly reconciliation process and ensure compliance in MMR report reconciliation.