Specialty Clinical Audits

Addresses costly claim drivers for high-cost drugs andĀ implants.

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.

High-Cost Drug 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 High-Cost Drug 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