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Cost Containment - SmartClaims

SmartClaims is a proprietary ABS system which allows us to control rising claim costs for our clients. This system utilizes a combination of technologies and industry expertise to target and locate savings.

SmartClaims:

  • Targets 100% of claims for savings.
  • Employs five highly effective cost-reduction strategies.
  • Uses Electronic Data Interchange (EDI) to avoid delays and preserve the integrity of the claims payment process.

How SmartClaims works:

Step 1 – Identify Suspect Providers.
  • Mines thousands of data sources for records of fraudulent billers
  • Identifies providers with a history of questionable billing practices as well as those who have been subject to prior claim investigations
  • Screens claims prior to issuing payment, yielding an average recovery of $0.54 for every questionably-billed dollar. Retrospective recovery or seeking reimbursement after a questionable claim has been paid yields an average of only $0.10 on the dollar.
Step 2 – Detect “Code Creep” or suspect provider bills. 
Using neural network technology that was originally developed to detect credit card fraud, SmartClaims:
  • Identifies patterns of unusual billing behavior prior to claim payment.
  • Employs a predictive model to spot new and unknown billing scams.
  • Scores every claim for the possibility of fraud, and subjects those with the highest scores to the greatest scrutiny.
  • Saves money by establishing reasonable fees for any corrected bills.
Step 3 – Find supplemental networks for discounts on Out-of-Network bills. 
While Out-of-Network claims are often a small percentage of total claims, the expenses associated with them represent an opportunity for significant savings. SmartClaims:
  • Searches more than 50 leading preferred provider organizations (PPOs) in order to secure discounts from 600,000 providers nationwide.
  • Finds PPO discounts on up to 50% of Out-of-Network bills.
Step 4 – Reduce costs even when Networks are unavailable.
Even with a nationwide supplemental network in place, some claims will fall outside of the discount structure described in Step 3. These claims are subject to close examination and ABS negotiates fee reductions.


Step 5 – Identify Third Party Coverage for Subrogation recovery opportunities.
SmartClaims uses legal counsel to check court dockets in order to find and identify potential recoveries from third parties. Claims are subrogated on members’ behalf with:
  • Automobile insurance companies
  • General liability insurance companies
  • Homeowners / renters insurance policies
  • Workers’ compensation insurance policies

For information about how ABS is using SmartClaims to control member claim costs, contact your ABS Sales Representative.