Specialty Clinical Audits

Addresses costly claim drivers for specialty Rx, implants and air ambulance.

Zelis Specialty Clinical Audits is a customizable audit program designed to address costly claim drivers that may typically be considered carve outs in health plan network contracts. This solution is managed through an integrated strategy driven by proprietary claim selection technology, clinical algorithms, an intense clinical audit and a unique approach to episode of care management.

Specialty Rx Solution

Specialty drug claims are some of the most complex since they often don’t have accurate coding, specificity in claims data, or monitoring and pass through for payment without adequate scrubbing. The Zelis Specialty Rx Solution resolves these challenges by focusing on specialty drugs covering all provider types, including Outpatient, Infusion Centers, Home Infusion and Specialty Pharmacies.

  • Zelis proprietary 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 us to manage and audit the member’s entire course of treatment versus one claim at a time, ensuring consistent outcomes
  • 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 market evolves


Implants Solution

Implant costs are growing exponentially due to the rise in orthopedic, neurological and stem cell-based implants combined with an aging population. The Zelis Implants Solution addresses key challenges with implant reimbursement to ensure billing accuracy and cost analysis.

  • Audit solution focuses on implant categories within cardiac, orthopedic and neurosurgery
  • 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


Air Ambulance

Our comprehensive approach helps reduce ambulance costs by extracting waste and abuse in out-of-network claims. This prepayment solution is managed through an integrated strategy driven by claim selection technology, clinical algorithms, and an intense clinical audit.

  • Clinical review includes medical necessity to confirm air transport was the most appropriate method of transport as well as validate parameters of logistical and mileage requirements to ensure appropriate level of care
  • Benchmark transport provider charges against accepted standards like Medicare to evaluate charge inflation
  • Direct contracting targets improved, repeatable secured savings on each claim
  • Experienced negotiators leverage knowledge of provider data and negotiation history to streamline negotiations & secure maximum savings