CMS collects information from diverse sources for Medicare Advantage entitlement, eligibility, and primacy status determinations–impacting monthly capitation payments reflected in the MMR.
Gain greater confidence in your premium payments with our Premium Integrity solution suite. We’ve developed tested tools and methodologies to identify and recover mistaken capitated premium payments and mitigate compliance risk.
This comprehensive Part C premium reconciliation evaluation identifies and predicts dual status.
Our Premium Integrity solution scrutinize the two key factors impacting premiums–Medicare Secondary Payer (MSP) validation and End-Stage Renal Disease (ESRD) status. It uncovers inaccuracies in your CMS reporting and better classifies complex diagnoses by reconciling inconsistencies between the Membership Monthly Report (MMR) and claims data. Allowing you to recover payments for members.
Our dual eligibility identification model improves member experience, expands benefits, and increases retention through data-driven outreach and ensures members’ plans are the best fit for their conditions. These tools quickly diagnose recovery opportunities or compliance concerns and predict dual status with up to 95% accuracy on average so that you get reimbursed accurately for these members.
Pareto’s solutions are built on our leading-edge data management platform that relies on data lake, artificial intelligence, and open-source big data technologies. It collects, aggregates, and organizes data, delivering analytics that optimize revenue, lower costs, improve quality of care, and achieve better outcomes.
Pareto can rapidly ingest structured, semi-structured and unstructured data from claims, clinical and social determinants of health data sources in real time, near real time, and batch ingestion.
Our platform relies on a highly adaptive technology stack based on complementary, industry-leading technologies—Spark, Kubernetes, Akka, Cassandra, and Kafka (SKACK).
The platform’s outputs feed real-time applications. We use machine learning to refine processes and artificial intelligence to achieve speed and scale.
We are committed to continuous innovations with a measured and responsible approach to putting them into practice. The predictive algorithms with the greatest return for our clients are thought through. They’re crafted and applied carefully and appropriately.
