How one payer realized $21M in savings with Alaffia

Intro

Discover how this trusted regional healthcare payer partnered with Alaffia to save time, reduce appeal noise, and deliver measurable savings.

“Alaffia is hands down the best vendor I’ve worked with in my many years in the claims operations space. Their high-quality complex reviews have saved our team hours of time and our organization millions of dollars.”

Challenge

Maintaining payment integrity across a large volume of high-dollar hospital claims

For a leading payer, strong financial stewardship is non-negotiable. Even one misstep in plan administration can trigger regulatory scrutiny or costly errors. That’s why the payer’s 50-person claims processing team works tirelessly to ensure their thousands of daily claims are paid accurately.

To maintain this high bar, the team outsourced line-item reviews for high-dollar hospital claims to a third-party vendor. Unfortunately, the vendor’s traditional review services left critical gaps, including arduous workflows and limited accommodation of payer requirements.

After taking stock of the vendor’s current constraints and reassessing the team’s internal needs, the payer’s VP of Operations decided it was time to upgrade to a cutting-edge new claim review partner.

She specifically searched for a solution with:

• High-quality, 100% auditable claim reviews
• The ability to accommodate client requirements, such as customizing reviews for multiple payment policies
• Intuitive, user-friendly claims approval workflows
• Accurate payment policy configuration
• Responsive, collaborative account management

Alaffia checked every box. As soon as the VP of Operations watched the demo and spoke with Alaffia’s expert team, she knew it was the right fit.

“Our responsibility is to be the very best stewards of our clients’ healthcare dollars, but high-dollar hospital bill reviews make that hard. We knew Alaffia would help us streamline this process and raise the payment integrity bar.”

Solution

Putting audit-ready complex reviews on autopilot with AI

With Alaffia, the payer meticulously uncovers every billing discrepancy or savings opportunity — with minimal internal lift.

The partnership started with a high-touch onboarding. Alaffia’s team customized their AI platform to the payer’s workflows, directly integrating each plan's specific policies, coding guidelines, and clinical criteria. And within a few weeks, the claims processing team was live with Alaffia and confidently processing high volumes of hospital claims.

As soon as claims are selected and subsequent documentation is attached, Alaffia’s AI platform:

• Runs AI-powered reasoning against the payer’s configured rules and criteria
• Triages the claims by complexity
• Surfaces a billing error recommendation backed by a rationale
• Passes that recommendation to Alaffia’s in-house coders and clinicians to validate, revise if needed, and sign off

And, because of Alaffia’s best-in-class technology and industry-leading subject matter experts, it never misses crucial nuance. From services billed without clinical documentation to inflated units of time-based services, Alaffia consistently digs deeper and finds more, translating dense clinical and billing data into quickly realized savings.

For the claims processing team, the transformation has been just as significant. With the full claim review workflow in Alaffia's expert hands, all they have to do is review the identified savings and action Alaffia’s recommendations.

This new workflow gives staff valuable time back and simplifies their work. “Alaffia has seriously improved the job satisfaction of our claims processors,” the payer’s VP of Operations explains. “They spend less time being frustrated and more time on the higher-stakes cases that need their touch.”

Claims processors also know that almost all of Alaffia's reviews will satisfy providers and withstand further scrutiny. By meticulously configuring its AI system to each plan’s specific policies and procedures, payers will experience fewer appeals and overall provider abrasion.

Alaffia’s on-demand account management and support team are the foundation of this success story. If a payer needs to adjust a configuration or test a new use case, Alaffia works closely with them to implement a new solution. The team proactively works to eliminate any potential friction in high-dollar hospital claim reviews.

“Since partnering with Alaffia, we’ve seen a notable decrease in both appeals and repeat appeals. Alaffia’s rigorous reviews and well-supported rationales really help us build trust with providers and strengthen those relationships.”

Results

Massive cost containment, valuable time back, and an appeal rate under 2%

Alaffia’s AI-driven complex reviews have become essential to the payer’s entire payment integrity operation. What was once a tedious, manual process that let meaningful savings slip away is now a streamlined, dependable workflow.

The results since the partnership began?

The payer looks forward to building on what’s already been a long, successful partnership with Alaffia.

“I can’t emphasize enough how top-notch Alaffia’s customer service is. The team goes out of their way to take care of their clients, which empowers us to do better by our members and providers.”