We are dedicated to enhancing the profitability of your managed care risk or performance-based contracts. Our extensive experience with multiple national and regional payers has given us the foundation necessary to find opportunities to improve your financial performance and get results.

Our Services

  • Claims contestation and overpayment recovery involves finding payment errors and getting them fixed. We identify overpaid claims, get them corrected, and get your money back.

    This is the bulk of what we do because it is where most all of the expense dollars and the errors occur. Often 3% or more of your claims expenses can be payment errors.

  • Revenue is the other side of the equation. We look for revenue shortfalls due to premium errors, dual-eligible premium terms being misapplied, and even inaccurate eligibility.

  • Some claims are paid the correct amount but should never have been paid based on dual-eligibility or division of financial responsibility (DOFR) contracts. We’ll make sure everything is right. Leakage is never good, but we know how to fix it for you.

  • We support clients with reinsurance/stop loss recovery compliance under health plans or third-party reinsurers. Let us take a look and make sure you get full credit for your coverage.

  • We can provide custom medical economics studies or standard reporting. ACO reporting and financial reporting for your downstream affiliate partners are common examples.

    If you can describe it, we can analyze and report on it. Just ask us.

  • If you’ve signed a contract, we’ll help you understand and manage the performance terms and make sure the financial reconciliation is accurate (see the bullets above).

    If you are about to enter into a risk or performance contract, let us take a look at it first. We’ve reviewed hundreds of these and can give you some insights of what to watch out for to aid you in finalizing your negotiations.

  • When things have gotten really uncomfortable, let us take a look and see if we can help. We can provide analytics and audits for litigation support and expert witness needs.

    From our experience with managed care contracts and billions of dollars of medical data, we can assist you with your legal disputes. We have experience serving as an expert witness and providing support to counsel.

“Nobody spends somebody else’s money as carefully as he spends his own.”

Milton Friedman

A Quick Primer On Risk & Performance

When we talk about risk or performance contracts we are referring to any agreement you have with a health plan under which you are financially accountable, or financially at risk, for the total cost of care of members assigned to your organization for care management. The health plan will assign a certain amount of revenue, usually referred to as funding and often represented contractually as a percentage of premium allocated to your performance P&L. Your members will receive medical services and incur claims expenses. These expenses are then reconciled against your contract’s funding to determine if you have achieved a surplus or a deficit.

All throughout this process there are opportunities for payment errors to occur. Mistakes happen. If their P&L says you are due a $5,000 surplus payment, that’s great, right? Not so fast. What if it really should be $7,500 or even $750,000? That’s where we come in.

Let Diadema Healthcare monitor and remedy your data to ensure you are fairly rewarded for your hard work.

We can transform basis points of payment errors into material value right to your bottom line.

That adds up quickly! What’s even better is that Diadema Healthcare works on a contingency basis for claims overpayment recovery efforts. Put simply, this means you don’t pay anything unless you benefit financially. So if you are receiving all of the premiums you are due and all of those claims have been paid accurately, you can have peace of mind that your P&L is perfect and none of your money has been left on the table -and it won’t cost you a thing. We’re not worried though, because we haven’t seen that happen yet -perhaps because we’re quite good at finding errors.

Let’s talk and then let us get working on maximizing your financial performance today!

But How Does It Really Work?

Our process is meant to be straightforward and easy on you. Once we have established our working relationship, your organization will share data over to us. We receive and analyze your data and look for any opportunity to improve your financial results. We pursue recovery issues directly with the health plans and keep you informed along the way.

While we are meticulous and diligent in our efforts, we always aim to make this as light of a lift on your team as we possibly can. Basically, it’s all about the data. Set us up with your source data and keep it current each month and we’ll take it from there.

Still got questions? Drop us a line and we’ll schedule a call. It would be our pleasure to discuss how we can help.