Comprehensive Payment Integrity Solutions

End-to-end coverage for pre-pay and post-pay claims with advanced AI and clinical expertise

Complete Payment Integrity Coverage

From pre-payment prevention to post-payment recovery, our solutions deliver comprehensive protection across the entire claims lifecycle

Pre-Payment Solutions

Pre-Pay Data Mining

  • Predictive claim scoring
  • Real-time eligibility verification
  • Automated prior authorization
  • Duplicate claim detection
  • Provider pattern analysis
  • Network adequacy validation

Pre-Pay Clinical Validation

  • Medical necessity review
  • DRG validation
  • Level of care assessment
  • Admission appropriateness
  • Length of stay optimization
  • Concurrent review automation

Post-Payment Solutions

Post-Pay Data Mining

  • Retrospective claim analysis
  • Overpayment identification
  • Coordination of benefits
  • Third-party liability
  • Subrogation opportunities
  • Provider audit targeting

Post-Pay Clinical Validation

  • Complex case review
  • High-dollar claim audit
  • SNF validation
  • ER leveling review
  • Readmission analysis
  • Quality measure validation

AI-Powered Data Mining Excellence

Our data mining solutions leverage advanced machine learning algorithms trained on billions of historical claims to identify patterns invisible to traditional rule-based systems

Key Capabilities

1. Pattern Recognition

  • Anomaly detection across provider billing patterns
  • Geographic variation analysis
  • Temporal trend identification
  • Peer group comparisons

2. Predictive Analytics

  • Fraud probability scoring
  • Risk stratification models
  • Cost prediction algorithms
  • Outcome forecasting

3. Network Analysis

  • Provider relationship mapping
  • Referral pattern analysis
  • Collusion detection
  • Supply chain validation

Technology Stack

AI & ML Framework

  • TensorFlow and PyTorch models
  • Real-time Apache Kafka streaming
  • Distributed computing with Spark
  • Graph databases for relationship mapping

Processing Power

  • 50M+ daily predictions
  • <100ms response time
  • 99.2% accuracy rate
  • Continuous learning updates

Proven Results

  • 45% increase in improper payment detection
  • 60% reduction in false positives
  • 80% faster processing times
  • $150M+ annual savings per client

Evidence-Based Clinical Validation

Our clinical validation combines board-certified physician reviewers with AI-assisted decision support to ensure every claim meets medical necessity and appropriateness standards

Service Lines

DRG Validation

  • MS-DRG and APR-DRG review
  • Principal diagnosis validation
  • Complication/comorbidity verification
  • Procedure code appropriateness
  • Clinical documentation improvement

SNF Validation

  • RUG score verification
  • Therapy minute validation
  • Medical necessity review
  • Consolidated billing compliance
  • Quality measure alignment

ER Level Validation

  • E&M code appropriateness
  • Facility level verification
  • Professional fee validation
  • Observation vs admission
  • Urgent care alternative analysis

Clinical Excellence

Expert Team

  • 500+ board-certified physicians
  • 1,000+ registered nurses
  • 200+ certified coders
  • 24/7 clinical support
  • Average 15+ years experience

Validation Process

  • AI pre-screening and risk scoring
  • Clinical criteria application
  • Evidence-based review
  • Provider collaboration
  • Appeal support and documentation

Quality Standards

  • 99%+ clinical accuracy rate
  • 24-hour turnaround for standard reviews
  • 2-hour rush review capability
  • Full regulatory compliance
  • Provider satisfaction focus

Calculate Your Potential Savings

See how much your organization could save with our AI-powered payment integrity solutions

Ready to Transform Your Payment Integrity?

Schedule a personalized demo to see how our solutions can deliver measurable value to your organization