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Payment Integrity Solutions

Comprehensive Coverage for
Pre-Pay & Post-Pay Claims

End-to-end solutions combining advanced AI with clinical expertise to maximize savings and minimize provider abrasion

Explore Data Mining Clinical Review
7,500+
Edit Concepts
8-10%
DRG Recovery
<5%
Overturn Rate
COMPLETE COVERAGE

Full Claims Lifecycle Protection

From pre-payment prevention to post-payment recovery, comprehensive protection at every stage

Pre-Payment Solutions

Pre-Pay Data Mining

  • Predictive claim scoring
  • Real-time eligibility verification
  • Automated prior authorization
  • Duplicate claim detection

Pre-Pay Clinical

  • Medical necessity review
  • DRG validation
  • Level of care assessment
  • Concurrent review automation

Post-Payment Solutions

Post-Pay Data Mining

  • Retrospective claim analysis
  • Overpayment identification
  • Coordination of benefits
  • Provider audit targeting

Post-Pay Clinical

  • Complex case review
  • High-dollar claim audit
  • SNF & ER leveling review
  • Readmission analysis
DATA MINING

Advanced Data Mining

7,500+ customizable pre-pay edits and post-pay recovery concepts

$12-$55 PMPY
Incremental Opportunity
<5%
Overturn Rate
7,500+
Data Mining Edits
Real-time
Pre-pay Processing

Edit Categories

  • Duplicates, eligibility, COB
  • CKD/ESRD and Drugs validation
  • Hospice, SNF, HH, DME
  • ER Leveling and Unbundling

Pre-pay Exchange

  • API/Integration: 1-2 minutes
  • Batch processing: 1-2 hours
  • Medical Records: 48-72 hours

Pre-pay Advantages

  • Improved payment quality
  • Eliminates collection activities
  • Less provider abrasion

Performance

  • Statistically valid sampling
  • ML and AI applications
  • Performance-based pricing
CLINICAL REVIEW

AI – Assisted DRG Clinical Review

AI-powered DRG validation identifying 8-10% overpayment recovery opportunity

Clinical Review Anticipated Savings Breakdown

5%
DRG Upcoding
2%
Short Stays
2%
IP Readmits
8-10%
Total Opportunity

Selection Criteria

  • Clinical complexity indicators
  • High dollar and outlier claims
  • Provider pattern analysis
  • DRGs targeted by RACs and OIG

Medical Record Acquisition

  • HIE network - up to 80% coverage
  • Integration with company medical records (EHR Systems)
  • Traditional HIM requests

AI Assisted Medical Record Review

  • Diagnosis & Procedure code DRG Validation using evidenced based, coding, and regulatory guidelines
  • Admit Source and Discharge Status Verification
  • Hospital Acquired Conditions (HACs) Identification
  • 100% human in loop emphasized

Security & Quality

  • All AI applications local - no external data
  • 100% nurse review on all findings
  • Less than 5% overturn rate

Targeted Clinical Review Services

5%
DRG Upcoding
  • CC/MCC validation review
  • Principal diagnosis accuracy
  • Procedure code verification
  • POA indicator validation
2%
Short Stays
  • 1-day stay medical necessity
  • Observation vs. inpatient status
  • Two-midnight rule compliance
  • Level of care determination
2%
IP Readmits
  • 30-day readmission review
  • Related condition analysis
  • Planned vs. unplanned admits
  • Transfer and split billing
$$$
Itemized Bill
  • Line-item charge review
  • Duplicate charge detection
  • Supply and implant verification
  • High-cost outlier validation
Ready to get started?

Transform Your Payment Integrity Today

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

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HIPAA Compliant
SOC 2 Certified
FDR Ready