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.
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.
Related content
Achieving Success In Claims Editing
Achieve Accuracy and Efficiency in Claim Pricing
