Pacific and its strategic partners represent over 30 years of pioneering breakthroughs in integrated loss control solutions. We provide healthcare clients with a total claims management solution.

Integrated Loss Control Solutions

Utilizing our strategic partner's proprietary claims management systems, we target $350 billion in healthcare claims overpayments to validate payment integrity and maximize cost savings for our clients. Pacific enables our clients to take advantage of multiple state-of-the-art loss control technologies through a single connectivity source to prevent paid claims errors on a pre-payment or post-payment basis, reducing paid claims by 3-10% annually.

^ Back to top

Fraud & Abuse Prevention Suite

The Fraud & Abuse Prevention Suite, powered by TC3 Health, is comprised of Five Proven and Proprietary Services Which Combine to Detect and Report Healthcare Fraud Detection and Deliver Reductions in Total Claims Costs of up to 6%.

Provider Integrity Program

Prospective Tools for Validating the Integrity of Provider Claims

Fraudulent healthcare claims generate a large portion of more than $350 billion in healthcare overpayments. Pacific provides healthcare payers with a highly effective system for healthcare fraud detection . Claims that are questionable or fraudulent are flagged and reviewed prior to payment. The spiraling cost of healthcare claims is at an all time high making fraud detection mechanisms not only a desirable business asset, but also a necessity.

The Provider Integrity Program ("PIP") is a comprehensive provider data analysis and modeling application designed to review healthcare claims that may represent questionable or abusive billing practices. Historically, PIP has provided savings in healthcare fraud detection in the range of 1% - 3% of total claims dollars which are in addition to any identified by internal systems or procedures.

To help detect healthcare fraud PIP examines and flags potential claims daily prior to payment. The review process identifies claims and providers processed by a payer's system and compares each claim against proprietary databases that are updated daily from ongoing investigations. This prevents claims from being paid out in error and provides the claim file documentation for the payment avoidance or the reduction in payment.

Intelligent Claim Surveillance

Neural Network Technology to Detect New and Emerging Fraud Schemes

Our Intelligent Claim Surveillance engine employs dynamic profiling and predictive technologies using all available historical information to quickly identify complex fraud schemes, including sophisticated duplicate schemes, that previously could not be identified, and uncover new and emerging schemes - before claims are paid.

The software identifies patterns of unusual behavior and provides a risk score based on the claim's degree or probability of fraud. The scores allow our seasoned team of fraud investigators to determine which claims need to be taken out of the payment stream for further investigation, and allow the rest of the claims to be fast-tracked for payment.

Case File Investigations

Prepayment Investigations Minimize Fraud Overpayments

Pacific's experienced investigative team uses the latest technology and a proven investigative process to maximize claims savings and minimize overpayments due to fraud and abuse.

Our investigative team members possess a good understanding of payer operations, and their investigative findings are reported in a manner that facilitates timely and effective use within our payer client's organizations.

The investigative team conducts each investigation in an objective and professional manner, with unbiased presentation of the facts. The investigators adhere to systematic, consistent methods to conduct investigations, yet recognize and handle the unique circumstances surrounding individual cases.

Code Edit Compliance

Code Edit Compliance Utilizing Sourced and Documented Defense Rules

The code edit rules engine utilized by Pacific is the most comprehensive in the industry comprising millions of clinical edits. All rules and edits are based on national industry standards sourced, documented and defensible from CMS, CCI and AMA.

The code edit application is designed to minimize manual intervention as 100% of the edits are backed by nationally recognized coding guidelines and all rules include supporting documentation accessible through a web-based browser. The code edit rules egine can also provide additional PPO savings as billed charges are reduced when properly coded and the network discounts are calculated from a lower base.

OFAC (Office of Foreign Assets Control) Regulatory Compliance for the Patriot Act

Pacific's services include an automated screening and compliance tool utilizing advanced search and matching technology to correctly identify SDNs (Specially Designated Nationals) and to alert the compliance office of potential regulatory requirements. The OFAC compliance system automates the search process, verifies identification against the SDN list and automatically flags questionable transactions.

^ Back to top

Repricing Optimizers Suite

The second suite of services Pacific offers in the integrated Loss Control Technologies suite is the Repricing Optimizer Suite, powered by TC3 Health. The services provided through this suite focus on 1) quickly and efficiently increasing PPO savings for payers by combining technology with access to 600,000+ providers to reprice retail claims, increasing PPO savings by 10 - 25% and 2) using proprietary data sets and benchmarks to establish reimbursement on retail claims and determine the appropriateness of charges, reducing claims by 1 - 3%. These tools are designed to supplement out-of-area coverage to address network gaps with existing provider networks and reduce the cost of out of network claims.

AccessPlus PPO Networks

Increase Network Savings Without Changing Benefit Plan

Out of network claims are an expensive fact of life for all healthcare payers. Pacific's AccessPlus PPO Network increases PPO savings for payers without changing plan design or benefit differentials. AccessPlus is designed to supplement out-of-area coverage to address network gaps with existing provider networks. AccessPlus provides payers with a tool to reduce the cost of out of network claims by supplementing their current PPO networks. Pacific has developed strategic relationships with national, regional and local networks to bring a customized network management solution to our clients that include access to over 4,500 hospitals and 700,000 total providers.

AccessPlus satisfies out of network claims repricing needs for healthcare payers by supplementing the plan's service offering with access to the nation's largest aggregated PPO network. The AccessPlus Network includes national access to hospital, physician (including specialist) and ancillary providers such as home health and DME.

Provider R&C Benchmarking

Settle Claims Utilizing Benchmarking

Pacific accesses multiple data sets to determine and benchmark the appropriateness of the charges for each confinement or procedure and negotiates each claim directly with the providers. The data sets include key cost-to-charge ratios, which are the basis for calculating reasonable and appropriate reimbursements on hospital claims.

Utilizing these data sets to negotiate claims for charge appropriateness sets Pacific far apart from prompt pay discount organizations. Pacific's R & C Negotiation Services apply to all types of claims, including inpatient, outpatient, physician, IV therapy, and other specialty claims (e.g. dialysis, DME). All negotiated settlements include provider sign-offs or written documentation indicating no balance billing to the member.

Data Analytics and Decision Support Systems

Healthcare Predictive Modeling, Data Warehousing, Web-Enabled Reporting and Analytical Tools to Accurately Assess Prospective Healthcare Costs: powered by TC3 Health and Thomson Reuters

Pacific offers a Decision Support System (DSS) that enables healthcare payers to solve their most important business issues by providing powerful analytic reporting and highly scalable data warehousing capabilities. It provides payers with a single platform to assure accurate and consistent information to support enterprise-wide decision making.

Payers are acutely aware that a small percentage of their participants, usually less than 20%, account for 80% of total health care payments. Early detection of potentially expensive medical care is essential for proper risk management. Pacific's healthcare predictive modeling tools arm risk bearers with real-time analysis of current at risk populations for early medical intervention in high cost cases.

The power of Pacific's Decision Support Systems offering stems not only from its comprehensive reporting and data integration capabilities, but also from its ability to significantly improve a plan's overall performance. Flexible reporting functionality allows for fast and easy reporting, while web-enabled technology provides the ability to broadly disseminate information to plan sponsors, employers, brokers and disease management personnel.

^ Back to top

High Cost Drug Program

Each year, healthcare payers spend increasingly more on claims for high cost drugs. While these drugs can be lifesaving for the patients who use them, their rising costs have dramatically impacted healthcare profitability.

Some providers are deliberately taking advantage of the healthcare industry's confusion surrounding the proper billing and payment for high cost drugs. Coupled with this, spending on high cost drugs is expected to be over $90 billion by 2010.

Pacific's High Cost Drug Program assists healthcare payers in navigating through the ever-changing landscape of high cost drugs. By combining specialty audit with consulting services, this Program not only helps clients identify and recover past overpayments, it also provides them ways to minimize inappropriate payments in the future.

Key services include:

  • Identifying "one-off" overpayments that can be promptly pursued with little or no review of supporting documentation or discussions with providers.
  • Identifying and addressing situations that require more extensive auditing through an "on-site" or "desk" review of a provider's supporting documentation. These situations may be identified based on factors such as total claims volume, unusual billing patterns and the uses and types of drugs being dispensed.
  • Reviewing various components of the organization's provider contracts, authorization processes and payment policies and procedures that may be leading to overpayments.
  • Applying a proprietary "360 degree approach" to auditing and consulting to ensure a thorough and comprehensive review designed to maximize overpayment identification and financial recoveries, as well as ongoing advice designed to fix existing problems and prevent future overpayments.

Pacific's High Cost Drug Program will help your organization significantly lower its expenditures on high cost drugs while improving profitability. In a segment of the industry where payer costs are skyrocketing, this should bring welcome news.

^ Back to top

Industry Challenges

Healthcare payers across the board are making healthcare cost containment a top-level priority as health care costs continue a six-year trend of double digit annual increases. This trend is expected to continue through 2011. Pacific provides a proven, cost effective system which delivers reductions in claims payments by 3-10% annually.

  • 2002 - Aetna discloses 11% payment error rate.
  • 2003 - BCBS Association estimates that 5 - 10% of healthcare claims are paid incorrectly Business Insurance March 2003.
  • 2003 - Fed Gov't negotiated more than $1.8B in healthcare fraud settlements.
  • 2004 - CMS announced 9.1% error rate.
  • 4 Billion transactions annually - 6.3% error rate HHS-OIG.
  • A staggering $226B is annually lost to healthcare fraud alone (and rising) 2008 National HealthCare Anti-Fraud Association.
  • More than $350 billion in overpayments in healthcare annually - overpayments include: missed PPO discounts, duplicate payments, TPL payments, Coordination of Benefits issues, upcoded, unbundled payments, billing errors, adjudication errors, payments to aberrant or abusive provider billings, etc.
  • Annual stop-loss premium increases driving demand for cost containment solutions.
  • Prescription drug costs have increased an average of 18% the past three years.
  • Trend toward more cost-shifting to employees, increasing consumer out-of-pocket health expenditures.
  • Claims systems not managing risk and payment integrity effectively.
  • HIPAA increases demand for electronically integrating claims transactions.
  • Increase in auto adjudication creates need for independent third party validation.

Healthcare fraud detection tools are utilized to quickly identify complex fraud schemes on a pre-payment basis through dynamic profiling, predictive technologies, and proprietary databases. Allowing payers to access over 700,000 providers nationwide to obtain PPO discounts reduces out of network claims costs. Further savings are realized through negotiations with Provider R&C's to establish reasonable reimbursement amounts for both in network and out of network hospital, outpatient, ancillary, and professional claims.

Healthcare predictive modeling offers financial and clinical early alert predictors to enhance risk management while profiling chronic diseases and potential catastrophic claimants. Pacific's proprietary modeling tool projects cost and impact of various plan design scenarios while a reporting system provides reliable information at the touch of a button.

^ Back to top