Recovery Vs Review: Proactive Payment Integrity

Artificial Intelligence (AI) has become a game-changer in the healthcare sector, in diagnosis, treatment, administration, and finance. Medical overpayment protection is one area where AI technologies show enormous potential for revolutionizing the healthcare field. Fraud, waste, and abuse charges costing healthcare payers an estimated $300 billion per year in the United States. Controlling overpayments is critical for healthcare payers to keep their margins tight and have the resources to provide for their members.

It's 1.5x more expensive for payers to pursue recovery of overpayments as it is to process the payment correctly the first time. However, most healthcare payers (Medicare/Medicaid, commercial health insurance plans, etc.) pay claims within 15 days of when they are submitted. With the sheer volume of claims that most healthcare payers process, and an estimated 80% of healthcare claims containing at least one erroneous charge, it’s tough to review charges and prevent these overpayments from being made.

That’s where Alaffia Health comes in. Alaffia leverages an innovative AI-driven platform to identify potential overpayments and request necessary supporting documentation. Their experienced team of payment integrity analysts reviews potentially overbilled claims for discrepancies. How can advanced AI technology help your organization stop overpayments before they happen? Let’s find out.

AI-Driven Medical Overpayment Protection

Artificial intelligence is a huge force multiplier when used for medical overpayment protection. It can sift through many more claims than any human analyst, seeking discrepancies and flagging problematic claims for further review.

Alaffia combines healthcare industry leaders and domain experts with their next-generation technology to proactively increase payment accuracy rates. Their AI platform scans high-dollar, error-prone medical claims for discrepancies.

This technology allows Alaffia to examine three times as many individual line charges, while human analysts focus on forensic audits of claims deemed most likely to contain errors. Not only does this mean Alaffia catches more overpayments, the system tracks fraud, waste, and abuse patterns over time and provides real-time data on past and current cases.

How Does AI Assist Medical Overpayment Protection?

Alaffia’s platform leverages several AI technologies. 

Natural Language Processing: Natural language processing is a type of AI technology that allows computers to understand and interact with text and spoken words. Alaffia's platform uses this to scan documentation and recognize possible discrepancies. 

Machine Learning: Computers can analyze massive amounts of data. AI-driven computing can learn from it. For example, AI might use machine learning to become nearly unbeatable at chess by analyzing every grandmaster chess game ever played. Alaffia’s platform learns by scanning and auditing healthcare claims in the same way.

Robotic Process Automation: AI’s strongest use cases are for tasks that are repetitive, rules-based, and high-volume. Computers accomplish these tasks faster and more efficiently than humans, leaving humans free for tasks that require more detailed analysis, imagination, and intuition.

Stopping Overpayments Before They Happen

Alaffia’s approach to medical overpayment prevention is simple. Our systems seamlessly integrate with our partner organization and they provide real-time claims data. Our AI-driven platform scans through $50K+ payable claims that are most prone to fraud, waste, and abuse.

When a potential discrepancy is detected, the platform proactively reaches out to providers for supporting documentation. 

Our payment integrity team conducts a forensic analysis of the claim and supporting documentation, such as patient charts and medical records. We then send a detailed report to the provider and agree on the appropriate amount to bill, after which we inform you of the revised amount. 

Our claims auditing platform keeps stakeholders informed at each step of the process. Detailed reporting shows the amount Alaffia saves you  through overpayment prevention.

A Proven Solution

Alaffia’s a proven payment integrity leader, with the right fusion of technology and expertise to make a difference in medical overpayment protection for your organization. Our platform allows us to process claims and records up to 25% more efficiently. We can stop overpayments before they happen.

You don’t have to take our word for it; Alaffia’s contingency-based fee structure means we only get paid for results. Set up a call and put our cutting-edge technology to work for you.