Proactive Monitoring and Management of Waste, Fraud & Abuse

The PremierSource Advantage system and proprietary processes further allow us to monitor and manage waste, fraud and abuse in your programs to more effectively manage costs without reducing benefits. We do this by monitoring the following data points, to name just a few:

  • Which employees are at risk of “double dipping” between medical, worker’s compensation and disability programs?
    We track and monitor claims activity between these programs in our fully integrated care management system
  • Which providers are exceeding the cost norms for a given Diagnostic Risk Group (DRG) or Episodic Treatment Group (ETG)?
  • Using a Performance Mix Index, which services are being over-prescribed by which providers who are operating outside of evidence-based guidelines for a given DRG or ETG?

With this data and our proprietary process for analyzing the data, our medical director is able to reach out and negotiate with the providers who are driving excessive volume outside of evidence-based guidelines. While exceeding evidence-based guidelines is sometimes warranted, our system is already risk-adjusted to account for complexities associated with given episodes. In addition, our medical director is skilled at knowing how to investigate and discern between a provider whose volume is warranted and a provider whose volume is egregious or revenue-driven versus being driven by quality outcomes.