Payors / payment integrity
Stop Paying and Chasing
Pay-and-chase finds the money months after it’s gone. Ana checks every claim against your contracts, edits and payment history before the payment run — and hands reviewers the evidence with the flag.
Pay and Chase, or Check and Pay
- Claims paid first, checked months later
- A sample reviewed; the rest go out unread
- Reviewers open five systems to build one case
- New checks wait in the rules-engine queue
- Every claim checked before the payment run
- The whole population screened on every run
- Each flag arrives with the claim’s history attached
- New checks written in plain English, reviewed like code
Every Claim, Not a Sample
Ana runs your checks across the whole population on the cadence your claim flow allows — contract variance, duplicates, NCCI and MUE edits, level-of-care drift — and surfaces only the few that need a person.
- Prepay ahead of the payment run, or post-pay across history
- Every flag scored and routed to the right review queue
- New checks written in plain English and reviewed like code
The Evidence Comes With the Flag
The payment record alone says clm-2291 was paid within the fee schedule. The contract history says the schedule had expired. Every flag arrives with the claim, its adjustments and the terms in force on the date of service already joined.
- Contract terms matched to the date of service
- The query that found it logged beside the finding
- Evidence exported for the provider letter or appeal
- 03/04 Claim received — CPT 27447 clm-2291 · northwest ortho $41,000
- 03/11 Paid on the fee schedule on file pmt-7781 $38,400
False Flags Close as Fast as They Open
A screen that buries reviewers in noise gets switched off. The same history that proves a finding clears the ones that aren’t — a reversal isn’t a duplicate, and the reviewer sees why in one view.
- Reversals and resubmissions followed automatically
- Cleared flags tune the check, so they stop recurring
- Every decision logged for audit
- 01/12 Payment — office visit clm-1042 · pmt-01 $840
- 01/19 Payment — corrected claim clm-1042-a · pmt-02 $840
Start With the Claims You Already Paid
The first run looks back, so the findings are in dollars before anything in the payment run changes. The checks that hold up then move ahead of it.
Run a Retro Scan
Bring a year of paid claims and the checks your team suspects most. We run them inside your cloud and work the flagged cases with your reviewers.
- 01A 30-minute call to pick the checks and the claims in scope
- 02We connect inside your cloud under a BAA — nothing leaves your environment
- 03Your reviewers work the flagged cases with us, on real claims
The Checks Plans Run First
- 01 Duplicate and corrected claims
Separate true duplicates from reversals, replacements and resubmissions by following the adjustment history — before anyone sends a letter.
- 02 Contract and fee-schedule variance
Compare every paid amount with the rate in force on the date of service, including amendments and carve-outs, and total what is recoverable by provider group.
- 03 Upcoding and level-of-care drift
Find providers whose E/M levels or inpatient admissions drift above specialty peers, with the member mix accounted for.
- 04 Unbundling and code edits
Apply NCCI and MUE edits across the history, not just the claim in hand, and catch the patterns a line-level edit misses.
- 05 Coordination of benefits
Spot members with other coverage from eligibility, pharmacy and claims signals, and pay in the right order.
- 06 Recovery reconciliation
Match recovery letters to receipts and offsets, and see exactly what is still open and with whom.
Read access, inside your environment, to paid claims, the contracts and fee schedules in force, the provider master and your edit policy. Your team picks the checks; we run them and work the flagged cases with your reviewers.