Alivia Expertise for Commercial Health Plans

Commercial

Commercial health plans face persistent challenges, from preventing financial losses due to fraud, waste, and abuse (FWA) and overpayments to ensuring payment integrity, navigating regulatory pressure, and managing data security and fragmented systems.

Alivia Analytics turns this complexity into opportunity through data-driven strategies, deep expertise, and proven performance across the claims lifecycle.

Our Expertise

We have deep expertise across Private Health Insurance Plans, Employer-Sponsored Insurance (ESI), Third-Party Administrators (TPAs), and Self-Insured Employers.

Alivia’s Products & Services Support:

  • Early FWA Detection that stops high-risk providers at the source with Pre-Pay Preventive Analytics and configurable rules.
  • Post-Pay Recovery Analytics that surfaces hidden leads, accelerates SIU investigations, and manages case workflows—supported by Clinical Audits and Data Mining to validate medical necessity, policy compliance, and uncover overlooked savings. Outsourced SIU is available when you have limited resources.
  • Powered by the Alivia 360™ platform that targets the “Gray Zone” between error, fraud, waste, and abuse, uncovering hidden recoveries that rules-based systems miss.
  • Enhance operational performance with advanced Data & IT Transformation services that streamline data integration, modernize legacy systems, optimize claims platforms, and safeguard PHI across environments.

Compliance & Security

Built for customer confidence, Alivia ensures data protection and privacy with HITRUST r2, SOC 2 Type 2, HIPAA, and NIST CSF compliance. Our Alivia 360™ platform, products, and websites meet rigorous security standards, safeguarding sensitive healthcare data while delivering secure, reliable, and compliant solutions for commercial health plans.

Industry Associations

Alivia’s experts collaborate with leading industry associations, contributing to healthcare payment accuracy discussions and sharing case studies, trends, and innovations. This includes the Blue Cross Blue Shield Association (BCBSA), the National Health Care Anti-Fraud Association (NHCAA), the California Association of Health Plans (CAHP), and others.

Frequently Asked Questions (FAQ)

Alivia Analytics provides comprehensive solutions to protect commercial health plans from financial losses. Our approach includes:

  • Early FWA Detection: Utilizing Pre-Pay Preventive Analytics and configurable rules to identify and stop high-risk providers and suspicious claims at the source, before payments are made.
  • Post-Pay Recovery Analytics: Surfacing hidden leads, accelerating Special Investigative Unit (SIU) investigations, and managing case workflows to recover funds that have already been improperly paid.
  • Clinical Audits and Data Mining: Validating medical necessity, ensuring policy compliance, and uncovering overlooked savings opportunities through in-depth review and analysis.
  • Outsourced SIU: Providing expert investigative resources when your internal teams are limited, ensuring no lead goes unaddressed.
  • Alivia 360™ Platform: This powerful platform targets the “Gray Zone” between error, fraud, waste, and abuse, uncovering hidden recoveries that traditional rules-based systems often miss by leveraging advanced AI and machine learning.

Alivia Analytics employs a multi-faceted approach to combat FWA. Our solutions include:

  • Pre-Pay Preventive Analytics: Stopping high-risk providers and fraudulent claims before payments are made, using configurable rules and advanced algorithms.
  • Post-Pay Recovery Analytics: Identifying hidden leads, accelerating Special Investigative Unit (SIU) investigations, and managing case workflows to recover improperly paid funds.
  • Clinical Audits and Data Mining: Validating medical necessity and policy compliance, and uncovering overlooked savings opportunities.
  • Alivia 360™ Platform: Powered by advanced AI and machine learning, this platform targets the “Gray Zone” where errors, waste, and subtle fraud schemes often reside, finding recoveries that traditional rule-based systems miss.

We possess deep expertise across various commercial healthcare entities, including:

  • Private Health Insurance Plans
  • Employer-Sponsored Insurance (ESI) providers
  • Third-Party Administrators (TPAs)
  • Self-Insured Employers

The “Gray Zone” refers to the area where improper payments are not always clear-cut fraud but can be a combination of errors, waste, or subtle abuse that is difficult to detect using traditional methods. For commercial health plans, this zone represents a significant source of financial leakage. The Alivia 360™ platform utilizes advanced AI and machine learning to analyze complex data patterns, uncovering these nuanced issues and revealing hidden recoveries that rules-based systems cannot identify.

Our Data & IT Transformation services are designed to significantly enhance a commercial health plan’s operational performance. We help plans by:

  • Streamlining data integration from disparate sources.
  • Modernizing outdated legacy systems.
  • Optimizing claims platforms for greater efficiency and accuracy.
  • Safeguarding Protected Health Information (PHI) across all environments. These transformations lead to better data insights, improved claims processing, and a stronger foundation for payment integrity.

Customer confidence is paramount. Alivia Analytics prioritizes data protection and privacy by adhering to stringent security and compliance standards. Our systems and processes are built to meet HITRUST r2, SOC 2 Type 2, HIPAA, and NIST CSF compliance requirements. This commitment ensures that sensitive healthcare data is rigorously safeguarded, delivering secure, reliable, and compliant solutions for our commercial health plan partners.

Our experts are actively engaged with leading industry associations, contributing to discussions on healthcare payment accuracy, sharing case studies, and exploring emerging trends and innovations. This includes collaboration with organizations such as the Blue Cross Blue Shield Association (BCBSA), the National Health Care Anti-Fraud Association (NHCAA), the California Association of Health Plans (CAHP), and others. This involvement ensures our solutions remain cutting-edge and aligned with industry needs.

“Alivia Analytics” and “Alivia 360” are trademarks of Alivia Analytics, LLC. All other trademarks, service marks, logos, and brand names referenced herein are the exclusive property of Alivia Analytics, LLC, unless otherwise stated.