About Payment Integrity
As the Healthcare ecosystem are getting more complex, Health Plans are witnessing an accelerated rise in fraud and waste across their processes. For Health plans it is getting more complex to reduce waste, drive payment efficiencies and ensure accurate payments. The traditional, retrospective models of pay and chase no longer support Health Plan in achieving their savings goals.
Exponential AI’s Decision Agent driven PI solutions delivers pre-emptive discovery of potential savings across the pre-pay and post-pay Payment Integrity Value Chain. The solutions continuously learns from feedback across all PI efforts providing new insights for the right intervention.
Intelligent Payment Integrity
Decision Agent based AI solution to improve detection, investigation and recovery processes
- The PI center provides an intuitive interface for practitioners to identify, mange and review recommendations, across the PI value stream.
- The Agent based recommendations proactively flags claims for potential waste and fraud across, Co-ordination of Benefits, Provider Audit and Claims Editing using historical patterns.
- The systems is configured to recommend possible resolution, possible claim actions and initiate relevant communication. The center allows practitioners to provide feedback to system to continuously improve recommendation.
- The PI solutions comes with a dashboard to monitor Key KPI across the Payment Integrity lifecycle.
- The dashboard provides financial, operational, throughput and decision agent insights to enable easy management across roles. It provides details such as average time saved for recovery, average staff utilization rate, average time to process etc.
- The reporting dashboard is easily configurable and customizable for your unique process needs. It also enable transfer of insights across processes.
- The operation centre deliver capabilities to manage the PI life cycle process.
- A collaborative tool, it allows managers, supervisors, process owners to allocate and mange work across investigators.
- The centre provides intelligent routing and prioritization based potential savings opportunities, financial inconsistencies and anomalies.
Drive Measure Business Impact
Maximize overpayment recovery, reduces improper payment waste, and promote provider and member satisfaction
Reduction in lead time
AI based COB identification and management has drastically reduced the process lead time improving provider and member experience.
Decrease in Administrative Costs
Decision Agent PI model enable reduction in administrative costs and drive seamless processing.
Reduction in FWA
Uses AI to enable discovery of fraud, waste and abuse patterns and trends in a continuous learning and adjustment mode
Impact accuracy with prospective intelligence
Ready to GO
PI is an agent driven is out of the box solution that comes with a smart start mechanism to immediacy start delivering value.
Built for your environment
PI works with your existing investments and can easily be customized for your requirements. You an configured and train our decision agents to identify saving opportunities unique to you.
From Retrospective to Prospective
Transform your PI efforts from retrospective to prospective to move away form the pay and chase model
Transparency, Control, Ownership
Experience seamless PI customized for your process. Drive transparent, explainable and trusted decision.