Claims Validation in Action
See how Claims Validation combines pre- and post-payment technology and expert services to maximize savings, reduce repeat errors and minimize provider abrasion.
No claim should process without validation
Many factors magnify claims validation complexity including:
- Ever-changing CMS rules
- Confusing and ambiguous payment policies
- Detailed and customized provider contracts
- Over 85,000 diagnosis codes
- Multiple forms of reimbursement
Our pre-payment validation uses predictive scoring with advanced machine learning to systematically analyze all claim types for billing errors. It suggests a hold, pend or deny action. All of this occurs after claims have been adjudicated but prior to payment.
Our post-payment validation process aligns with our pre-payment validation to conduct look-back reviews of claims paid prior to instituting a pre-payment validation process.
Post-payment validation continues to identify claims with errors not appropriate for a pre-pay audit. Certified coding professionals can conduct post-payment audits onsite or remotely.
What makes our Claims Validation unique?
We can validate all professional and facility claims and offer both pre- and post-payment reviews to maximize results. Our validation includes daily predictive scoring to:
- Accurately and quickly identify potential errors
- Flag providers
- Validate charges
- Reduce repeat errors
We cast the widest net to catch fraud, waste, abuse and errors along the payment lifecycle. Applying pre-pay and post-payment validation and audits is more effective. It also reduces provider abrasion and optimizes your results.
Claims Validation results
We have an unmatched ability to select the right claims for audit:
- 100% of your claims are risk scored daily
- Our true positive rates can approach 70% or more
- Less than 2% of appeals are overturned
Our integrated pre- and post-payment solution can save 2–5% of your medical expenses. This could generate hundreds of millions in medical expense savings each year.