DataChrome™ in Action
Our data fabric solution is closely supported by world-class software, database, and cloud providers.
Specialized Services
Data Management & Standardization
- Ingests claims, eligibility, provider, and reference data from multiple sources
- Applies custom mapping, profiling, and transformation to create analytics-ready formats
- Supports pre-pay analytics, post-pay recovery, and broader enterprise data strategies
Architecture & Infrastructure
- Designs scalable, secure pipelines to support Alivia 360™, EDWs, data marts, and AI workflows
- Implements and modernizes cloud and on-prem databases, including Snowflake, Azure Data Lake, and Google BigQuery
- Performs legacy system migrations and infrastructure upgrades with minimal disruption
Assessment & Optimization
- Evaluates data quality, pipeline performance, and platform readiness
- Identifies gaps and inefficiencies across ingestion, staging, and reporting environments
- Reviews database licenses, architecture, and configuration for compliance and efficiency
Security & Governance
- Implements PHI/PII masking, encryption, and access controls
- Supports HIPAA compliance and payer-specific security protocols
- Delivers audit-ready data lineage, version control, and traceability
Contact Alivia Today!
Please fill out the form below. No pressure, just a productive discussion with one of our solution experts to address your needs.
Knowledge Bank
What Is Data Mining in Healthcare Payment Integrity?
Data mining in healthcare payment integrity involves the systematic analysis of vast claims datasets to identify anomalies, billing errors, and patterns indicative of overpayments or fraud. By leveraging advanced analytics and machine learning, organizations can proactively detect and address issues that traditional auditing methods might overlook.
Benefits of Implementing Alivia’s Data Mining Solution
- Enhanced Detection: Identify complex billing patterns and high-risk claims that may lead to overpayments.
- Cost Savings: Reduce improper payments and associated recovery costs.
- Improved Compliance: Ensure adherence to regulatory standards and internal policies.
- Operational Efficiency: Automate routine tasks, allowing staff to focus on more strategic activities.
Alivia Analytics’ Approach to Data Mining
- Proactive Claims Validation: Continuous monitoring to detect billing errors, coding inaccuracies, and policy discrepancies throughout the claims lifecycle.
- Tailored Edits & Compliance: Customizable editing rules aligned with CMS, AMA, state-specific regulations, and internal payer policies.
- Flexible Processing Options: Support for real-time validation and scheduled batch processing to streamline operations.
- Integrated Workflow: Seamless integration via API or batch processes, minimizing disruption and enabling unified oversight.
Frequently Asked Questions (FAQ)
What is non-clinical data mining in healthcare?
Non-clinical data mining refers to the use of advanced analytics and AI to evaluate claims data without reviewing clinical documentation like patient charts or records. It focuses on billing patterns, payment codes, frequency of service, and policy adherence to uncover errors, overpayments, or fraud. Alivia’s non-clinical approach allows for rapid, scalable analysis across high volumes of claims.
What is a Diagnosis-Related Group (DRG) readmission, and why does it matter?
A DRG readmission occurs when a patient is readmitted to a hospital shortly after discharge for the same or a related condition. Improper DRG readmissions—especially those that do not meet medical necessity or that are billed as separate unrelated events—can lead to overpayments. Alivia’s DRG Readmission Review identifies these cases to ensure proper reimbursement and reduce payer risk.
What are duplicate claims, and how do they impact payment integrity?
Duplicate claims happen when a provider submits the same service more than once—either accidentally or fraudulently. This can result in duplicate payments and inflate healthcare costs. Alivia’s Duplicates and Contract Compliance review flags these instances to ensure claims are paid only once and according to contractual agreements.
What is Non-Emergency Medical Transportation (NEMT) fraud?
NEMT fraud involves improper billing for transportation services provided to patients for non-emergency medical care (e.g., trips to dialysis or doctor’s appointments). Examples include billing for unprovided rides, inflating mileage, or using unqualified drivers. Alivia’s NEMT Review analyzes patterns in transportation claims to detect and stop abusive billing behavior.
What types of errors are common in Skilled Nursing Facility (SNF) billing?
Skilled Nursing Facility (SNF) billing errors may include:
- Billing for days when a patient was not in the facility
- Incorrect per-diem reimbursement codes
- Overutilization of services beyond the allowable scope
Alivia’s SNF Review uncovers these inaccuracies and validates alignment with CMS reimbursement policies and utilization guidelines.
What is Contract Compliance in claims processing?
Contract compliance ensures that claims are paid in accordance with the payer–provider agreement, including:
- Negotiated rates
- Service coverage terms
- Bundled payment conditions
Alivia uses automated rules engines to evaluate whether the claim matches the contract terms, ensuring fair and accurate reimbursement.
How does Alivia 360™ integrate these reviews?
The Alivia 360™ platform consolidates data mining, audit automation, and rules-based decision support into a unified system. Modules such as:
- DRG Readmission Review
- Duplicates and Contract Compliance
- NEMT Fraud Detection
- SNF Billing Review
…work together to deliver unmatched accuracy, speed, and regulatory compliance—whether as Software-as-a-Service (SaaS) or fully managed Payment Integrity (PI) services.
