Payment Integrity Record Retrieval Solutions Comparison

PLAN BENEFITS
RECORD RETRIEVAL SOLUTIONS FUNCTIONS
INSOURCEOUTSOURCEPORTAL REQUEST TECHNOLOGYAUTOMATED TECHNOLOGY
Plan sends remote retrieval requests fulfilled by providerPlan performs on-site retrieval requestsPlan sends remote retrieval requests fulfilled by providerPlan performs on-site retrieval requestsTechnology vendor sends on-demand requests via portalCAVO Connect uses FHIR calls to extract records
Automate record retrieval processRecord availability timelineHours – weeks, dependent on provider staff workload and delivery methodHours – days, dependent on plan staff workloadHours – weeks, dependent on provider staff workload and delivery methodHours – days, dependent on plan/vendor staff workloadMinutes – days, dependent on provider response timelineReal-time
Record capturing processManual by provider staffManual by plan staffManual by provider staffManual by plan’s record retrieval vendor staffManual by plan or plan’s record retrieval vendor staffAutomated via API, directed by payer-provider contract
Record yieldDependent on provider staff bandwidthDependent on plan staff bandwidthDependent on provider staff bandwidthDependent on plan’s record retrieval vendor staff bandwidthDependent on plan’s record retrieval vendor staff bandwidthOnly limited by configurable guardrails agreed upon with provider
Increase claim review productivityRecord format and data received by plan for reviewPDF image (with/without metadata)PDF image (with/without metadata)PDF image (with/without metadata)PDF image (with/without metadata)PDF image (with/without metadata)PDF image (metadata + discrete data) and discrete clinical information (optional)
Minimize provider abrasionOngoing provider administrative burdenYes – release of information + potential follow-up and duplication of requestsMinimized – EMR user access, vendor/visitor credentialing, etc.Yes – release of information + potential follow-up and duplication of requestsMinimized – EMR user access, vendor/visitor credentialing, etc.YesNegated/None
Provider revenue risk analysis (optional provider service)NoNoNoNoNoYes

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