Emdeon Acquires EquiClaim to Expand its Payment Integrity Solutions Offering


We are excited to announce Emdeon has acquired EquiClaim, a leading provider of post-payment healthcare claims audit and recovery services for commercial and government payers, from MultiPlan. EquiClaim’s programs enable Emdeon Payment Integrity Solutions to offer healthcare payers a more comprehensive suite of prospective and retrospective payment integrity services. EquiClaim’s offerings, now named Emdeon Audit and Recovery Services, are designed to provide credible and objective programs that help payers reimburse providers appropriately and provide a foundation for both parties to improve the payment process.


Emdeon now offers commercial and government payers:
• Robust payment integrity services with enhanced audit capabilities, enabling retrospective recoveries for improper payments

• Improved payment integrity through enhanced intelligence, for claims review in accordance with medical billing guidelines, contractual obligations and reimbursement rates and policies

• Recovery audit contractor (RAC) services, specifically for the government sector, in support of the program the Centers for Medicare and Medicaid Services (CMS) introduced in 2005 and recently rolled out to state Medicaid programs

• More tools to help reduce general and administrative costs, by improving the accuracy of the claims payment process and the recovery of improper payments

• Enriched, comprehensive payment integrity solutions that include both pre-adjudication validation (clinical code validation, provider verification, predictive and rules-based fraud detection software and analytics), as well as post-adjudication validation (special investigative unit services, post-payment audits for contract compliance, and hospital bill audit and diagnosis-related group (DRG) audit services

With this acquisition, Emdeon furthers its goal of helping payers make appropriate payments as well as working to make sure providers receive reimbursements from payers that meet negotiated, contracted rates.

How Emdeon Audit and Recovery Services Can Help with ICD-10 Transitions
CMS reports that mandated claims coding changes (from ICD-9 codes to new ICD-10 codes) will likely cost the health insurance industry more than $1 billion. CMS also anticipates an initial 10 percent increase in the number of claims rejected for improper coding.

Adding EquiClaim's capabilities to Emdeon's Payment Integrity Solutions offers Emdeon's payer customers more tools and expertise to help meet this regulatory-driven challenge. It also further positions Emdeon to help its government and commercial customers' initiatives promote cost-effective healthcare and reduce fraud, waste and abuse (FWA).

EquiClaim was one of the first subcontractors for CMS's RAC program. As mentioned above, CMS introduced the RAC program in 2005 and recently rolled it out to state Medicaid programs under Section 6411 of the Patient Protection and Affordable Care Act. The RAC program is a cost-containment effort intended to reduce improper payments within the Medicare and Medicaid programs. It also aims to identify process improvements that could reduce or eliminate future improper payments.

EquiClaim's capabilities give Emdeon more ways to help its payer customers resolve payment issues arising from increasingly complex provider contracts, reimbursement methodologies and claim payment policies. Emdeon’s end-to-end prospective and retrospective payment integrity solutions can help payers be more efficient and improve cash flow.

To discover more about Emdeon Payment Integrity Solutions, visit www.emdeon.com/paymentintegrity.


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