Payment Solutions Platform for
Pre-Pay & Post-Pay Claims
End-to-end solutions combining advanced AI with clinical expertise to maximize savings and minimize provider abrasion
Full Claims Lifecycle Protection
Pre-pay and post-pay reviews working together to ensure accurate claims processing — safeguarding plan integrity at every stage.
Pre-Pay Audits
Reviews performed before claims are paid — preventing errors and fraud at the source through data validation, policy-compliance checks, and benefit utilization reviews. Identifying issues early lowers administrative cost and improves provider satisfaction by paying the claim correctly with the first submission.
Strengths
- Includes low-dollar claims
- Fewer contract exclusions
- Fraud, waste & abuse prevention
- Strong vendor ROI
Opportunities
- Ongoing quality improvement
- Reduced provider abrasion
Post-Pay Audits
Reviews performed after claims have been processed to identify and recover overpayments. Pattern analysis across large data sets uncovers inappropriate payments — refining payer strategies, informing provider education, and continuously improving claim-accuracy models.
Strengths
- Back sweep of overpaid claims
- Gauges market reaction & quality before pre-pay launch
- Improves Encounter submission
- Optimizing health plan financial management through accrual accounts
Opportunities
- Prioritizes pre-pay initiatives & quality improvement
- Informs provider education & policy refinement
Advanced Data Mining
7,500+ customizable pre-pay edits and post-pay recovery concepts
Pre and Post-pay Edit Categories
- →Duplicates, eligibility, COB
- →CKD/ESRD, Drugs and biologics
- →Hospice, SNF, HH, DME
- →ER Leveling and Unbundling
Pre and Post-pay
Exchange
- →API / Integration
- →Batch processing
- →Medical Records (EHR)
Pre and Post-pay Advantages
- →Improved payment quality
- →Eliminates collection activities
- →Less provider abrasion
Quality Standards
- →Clinical policy review and write up
- →Payment policies review
- →Concept white paper authoring
AI – Assisted DRG Clinical Review
AI-powered DRG validation identifying 8–10% Savings opportunity
Selection Criteria
- →Clinical complexity indicators
- →High dollar and outlier claims
- →Provider pattern analysis
- →DRGs targeted by RACs and OIG
Medical Record Retrieval
- →HIE network — up to 80% coverage
- →Integration with (EHR Systems)
- →Traditional HIM requests
AI Assisted Medical Record Review
- →Diagnosis & Procedure code DRG Validation using evidenced based, coding, and regulatory guidelines
- →Admit Source and Discharge Status Verification
- →Hospital Acquired Conditions (HACs) Identification
Security & Quality
- →All AI applications local — no external data
- →100% nurse review on all findings (Human in loop)
- →Less than 5% overturn rate
Transform Your Payment Integrity Today
Schedule a personalized demo to see how our solutions can deliver measurable value to your organization