About Payment Integrity
As the Healthcare ecosystem is getting more complex, Health Plans are witnessing an accelerated rise in fraud and waste across their processes. Plans are finding it harder to reduce waste and drive payment efficiencies and ensure accurate payments. The traditional, retrospective models of pay and chase no longer support Health Plans in achieving their savings and accuracy goals.
Exponential AI’s Decision Agent driven PI solutions deliver pre-emptive discovery of potential savings across the pre-pay and post-pay Payment Integrity Value Chain.
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, manage and review recommendations across the PI value stream.
- Decision Agents proactively screen and flag claims for potential waste and fraud across Co-ordination of Benefits, Provider Audit and Claims Editing.
- Provides recommendations of possible resolutions, triggers claim actions and initiates relevant communications.
- The PI solution comes with a dashboard to monitor Key KPIs across the Payment Integrity lifecycle.
- The dashboard provides financial, operational, and decision agent insights. It provides details such as average time saved for recovery, staff utilization rate, processing time.
- The reporting dashboard is easily configurable and customizable for your unique process needs. It also enables transfer of insights across processes.
- The operations centre delivers capabilities to manage processes across the full PI life cycle.
- A collaborative tool, it allows managers, supervisors and process owners to allocate and manage work across investigators.
- The centre provides intelligent routing and lead prioritization to maximize savings and recovery across internal and external teams.
Drive Measurable Business Impact
Maximize overpayment recovery, reduce improper payments, and improve provider and member satisfaction
Reduction in lead time
AI based COB identification and management drastically reduces process lead time leading to better provider and member experience.
Decrease in Administrative Costs
Decision Agent PI model enables reduction in administrative costs and drives seamless processing.
Reduction in FWA
Uses AI to enable discovery of fraud, waste and abuse patterns and trends in continuous learning and adjustment mode
Impact accuracy with prospective intelligence
Ready to GO
PI is an agent driven, out of the box solution that comes with a smart start mechanism to immediately start delivering value.
Built for your environment
PI works with your existing investments and can easily be customized for your requirements. You can configure and train decision agents to identify saving opportunities unique to you.
From Retrospective to Prospective
Transform your PI efforts from retrospective to prospective to move away from the pay and chase model
Transparency, Control, Ownership
Experience seamless PI customized for your process. Drive transparent, explainable and trusted decisions.