SolutionS
Payment Integrity Solutions
Stop leakage before it happens.
Identify, prevent, and recover improper payments with transparent, defensible controls.
Payment Integrity combines prepay prevention and postpay recovery to ensure claims are paid accurately and only once. The solution analyzes claims with policy, coding, clinical, and contract logic to flag issues such as duplicates, upcoding, unbundling, medically unlikely edits, site‑of‑service mismatches, and non‑covered services. High‑confidence findings trigger prepay edits or provider validations, while complex cases route to specialist review with clear evidence packages. Postpay analytics mine paid claims for patterns of overpayment and coordination‑of‑benefits errors, launching recoveries with complete audit trails.
Workflows are governed, collaborative, and provider‑aware. Reason codes and documentation requests are specific and actionable, minimizing abrasion and speeding resolution. Integration with adjudication, SIU/FWA, and provider data ensures consistent policy application. Dashboards track identified savings, net yield, average days to resolution, provider response rates, and appeal overturns so leaders can tune rules, documentation standards, and targeting strategies for sustained value.
Prepay Edits That Prevent Leakage
Apply business, coding, clinical, and contract rules to stop improper payments before they occur.
Duplicate, COB, and Frequency Controls
Detect duplicates, coordinate benefits accurately, and enforce frequency limits to avoid overpayments.
Clinical and Coding Integrity
Identify upcoding, unbundling, MUE/NCCI violations, and site‑of‑service inconsistencies with explainable logic.
Contract and Pricing Validation
Verify fee schedules, DRG/APC grouping, and contractual terms to ensure correct allowed amounts.
Targeted Postpay Recovery
Use analytics to find overpayments and initiate recoveries with clear evidence and governed workflows.
Provider‑Friendly Resolution
Send precise reason codes and documentation requests to reduce abrasion and accelerate closure.
Appeals Management
Track overturns, root causes, and timelines to strengthen prepay logic and provider guidance.
SIU/FWA Collaboration
Escalate suspicious patterns to special investigations with packaged evidence and chain of custody.
Analytics and Continuous Tuning
Monitor identified savings, net yield, cycle times, and provider response to refine rules and focus areas.
Compliance and Auditability
Maintain complete audit trails, role‑based access, and evidence retention to support reviews and accreditation.
Benefits
- Reduce improper payments through strong prepay prevention and precise postpay recovery.
- Lower rework and provider abrasion with clear reason codes and evidence.
- Shorten resolution times using governed workflows and targeted outreach.
- Improve financial performance with higher net yield and sustained savings.
- Increase policy consistency by aligning edits, pricing, and contracts across systems.
- Strengthen compliance with full audit trails and transparent decisioning.
- Adapt quickly to new coding and policy changes with configurable rules.
- Scale across lines of business with interoperable, analytics‑driven operations.
