checkmark in a box iconSpecialty Clinical Audits

Specialty Clinical Audits is a customizable audit program that addresses costly claim drivers that may generally be considered carve outs within health plan network contracts.  This pre-payment solution is managed through an integrated strategy driven by Smart Logic claim selection technology, clinical algorithms, an intense clinical audit and a unique approach to episode of care management.

Our portfolio of solutions consists of High Cost Drug and Implants:


High Cost Drug Solution

Specialty drug claims are some of the most complex since claims with high cost drivers often don’t have accurate coding, specificity in the claim data or monitoring and pass through for payment without adequate scrubbing. Our solution resolves those challenges through our prepayment High Cost Drug audit solution, which focuses on specialty drugs covering all provider types, such as Outpatient, Infusion Centers, Home Infusion, and Specialty Pharmacies.

  • Smart Selection technology facilitates identification of high cost specialty drug claims and triggers flags for unsubstantiated medical claims and egregious costs
  • Embedded clinical algorithms focus on the drugs driving
    the most cost
  • Episode of care management allows Zelis to manage and audit the member’s entire course of treatment vs a claim at a time ensuring consistent outcomes
  • Complements Case Management/Pre-Authorization/Utilization Review
  • Ensures patient receives clinically approved evidence-based care at the most appropriate cost
  • Proactive monitoring of the specialty drug pipeline  adapts our solution as the high cost drug market evolves

Implants Solution

Implant costs are exponentially increasing due to the rise in orthopedic, neurological and stem cell based implants combined with an aging population. These costs can be unpredictable and inconsistent, thus a major concern for payers. The Zelis Implants solution is a prepayment solution for addressing key challenges with implant reimbursement ensuring billing accuracy and cost analysis.

  • Audit solution focuses on implant categories within Cardiac, Orthopedic and Neurosurgery
  • Compliments Pre-Certification
  • Audit ensures clinical appropriateness of device used and billed
  • Concentration on specific implantable devices that may have little FDA oversight
  • Enforcement of Medical Policy through focused clinical audit