Audit line-level charges with AI that extracts and validates details from complex clinical records, helping identify overcharges and reduce improper payments with greater precision.
Ensure accurate DRG assignments using AI that analyzes clinical documentation to detect miscoding, prevent revenue leakage, and reduce downstream audit risk.
Strengthen payment integrity across the full lifecycle with AI that flags issues before payment and audits claims post-payment to recover missed dollars.
Identify preventable readmissions and validate clinical justification with AI that analyzes patient histories and documentation, helping reduce unnecessary costs and improve audit accuracy.
Traditional payment integrity vendors rely on slow, expensive manual clinical review, inflexible rules-based claims editing, and costly retrospective data mining. We take a different approach, using purpose-built AI agents to ingest thousands of pages of medical records and cross-reference extracted clinical facts against the plan’s specific clinical criteria and policy guidelines.
Routine cases are automated and the most valuable claims are prioritized for human review, with every recommendation backed by a clear clinical rationale with traceable source citations. This results in faster reviews, higher accuracy, lower cost, and fully defensible findings.
Our managed services and SaaS solutions support utilization management, payment integrity, and appeals by giving teams the clinical context and operational intelligence they need to work faster and with greater accuracy.
By automating the intake, summarization, and cross-referencing of medical records against clinical criteria and coding guidelines, we dramatically increase the throughput and accuracy of clinical reviewers across all these program areas, driving consistently better outcomes across the entire claims lifecycle.
Our platform integrates seamlessly with existing claims management systems, EHR data feeds, and clinical criteria tools. It does not require health plans to replace existing infrastructure.
Yes. Our solutions support clinical workflows across the entire claims lifecycle.
We’ve achieved a 97%+ accuracy rate across all client implementations.
We get up and running in just 30 days from contract to production, with immediate ROI. Integration into your current systems is seamless, with no disruption to your operations or changes to your workflows.
Alaffia doesn’t replace your clinical team — it makes them even more valuable. Our AI agents increase throughput 20x, routing clear approvals for immediate processing while flagging complex cases. That frees up your clinicians to work at the top of their license, focusing their time and expertise where it matters most instead of dealing with routine cases.
As for vendors: we support clinical workflows across the entire claims lifecycle, whereas most vendors are point solutions that only handle specific workflows or sub-problems. Our unique hybrid engagements are tailored to meet you where you are, so we are capable of replacing multiple vendors if that’s what makes sense for your plan.
Privacy, security, and compliance are built into every layer of our solutions. We adhere to SOC-II Type II, HIPAA, and HITRUST security standards, and we establish and implement custom governance controls. All data stored within our platform is encrypted in transit and at rest, with 256-bit encryption to protect confidentiality and privacy.
Yes. Building alongside your team, we configure our software to meet any clinical needs you have, with your plan’s specific data, policies, and processes integrated into our AI platform to create bespoke workflows and outputs. Our AI agent will mimic your audit process and follow your decision tree on the way to making recommendations.
