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Claims Validation

Validate all claims through pre-payment and post-payment reviews while minimizing provider abrasion.


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.

Predictive scoring models, provider flags; DRG, outpatient, carve-out validation, analytics

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.

Add Claims Validation to your payment integrity portfolio today.

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