FW&A Trends: Using Data Analytics To Identify Opportunities

With fraud, waste, and abuse costs at an all-time high for healthcare payers, a robust payment integrity program is more important than ever before.  Many healthcare payers are turning to third-party payment integrity providers to address the massive volume of claims and documentation involved in payment integrity. But healthcare payers are also recognizing the value in big data, and a payment integrity partner that can provide relevant insights through healthcare analytics is especially valuable in this day and age. 

Alaffia Health’s next-generation AI-driven platform increases efficiency and allows Alaffia’s expert payment integrity analysts to identify and prevent fraud, waste, and abuse-related overpayments to healthcare providers. Healthcare payers with 100K members can recognize a $15 million annual savings by partnering with Alaffia, based on an estimated $150 potential annual savings on a per-member basis. 

Alaffia’s technology allows medical billing and coding experts and analysts to review more claims, and focus their efforts on the claims most likely to contain high-cost errors or overcharges, but it also allows Alaffia to provide deep insight into the payment integrity challenges your organization faces. Let’s look at how this works. 

Fraud, Waste, and Abuse: The Challenge

80% of American healthcare claims are billed incorrectly. Experts estimate that fraud, waste, and abuse charges handle $300 billion in annual costs to the U.S. healthcare system. That’s $650 in estimated F,W&A-related costs per plan member, per year! With healthcare costs rising across the board and the healthcare sector facing new challenges in recovering from the COVID-19 emergency and evolving federal legislation, the pressure on healthcare payers to control costs and margins has never been greater. 

The most complex, high-cost claims are the most likely to contain overpayments, yet they’re also the ones that require the largest investment of time to obtain and parse documentation. Payment integrity analysts can only review so many claims per day, and thus many of the claims most likely to contain F,W&A charges fall through the cracks. 

The Alaffia Solution

Alaffia Health provides pre-payment auditing of the high-cost, error-prone claims that are so often missed by internal teams. We review documentation to ensure that healthcare payers don’t make overpayments because of improper billing. 

1.2% of all plan members are ‌high-cost claimants, but they make up over 50% of healthcare spend, with an average annual cost of $122,382. Those members deserve top-notch care, but controlling those costs is critical to keeping costs down for everyone. 

Alaffia’s cutting-edge AI technology uses advanced healthcare analytics to serve as a massive force multiplier, identifying claims most likely to contain errors, requesting supporting documentation from providers, and then cueing up the claim for review by one of our experienced payment integrity analysts. This approach allows us to review three times as many claims and process them 25% more efficiently. 

The initial AI-driven review process means our team focuses solely on claims most likely to contain errors, so we catch more overpayments. It’s a fusion of technology and human know-how that simply works. And we believe in it enough that we charge no upfront fees or fixed costs; our fee is contingency-based, determined by the amount of money we save our partners. 

Healthcare Analytics: The Hidden Advantage

Our AI platform relies on and generates tremendous volumes of data, and besides the money we save our partners, we provide an even more valuable benefit: access to the fraud, waste, and abuse trend analytics generated by our platform. 

Our platform is a turnkey solution; we integrate with your systems and immediately begin reviewing claims and generating your savings. We also immediately begin generating data. You’ll receive a detailed report on the additional savings we generate for you with each claim and the accurate amount agreed upon with the provider after our review. Our platform also grants you full access to real-time data on past and current claims in-process, 

Our system detects and tracks fraud, waste, and abuse charges and patterns over time. We give your organization healthcare analytics that provide actionable insights into trends and the expected future billing behaviors of providers and facilities. 

If your organization has its own payment integrity team analyzing claims for potential F,W&A charges, or even when you’re trying to plan and project F,W&A costs when setting prices and copays for the coming year, this is invaluable information. 

The Bottom Line

The savings we generate for our partners is an enormous incentive to partner with Alaffia, but actionable data and healthcare analytics are critical for healthcare payers. By leveraging our analytics, you can help lessen the impact of fraud, waste, and abuse on your oganization in multiple ways. 

It’s easy to get started with Alaffia Health. It just takes a few minutes to discover all we can do to prevent overbilling and improve your bottom line. Contact us today to learn more.