Key Features
- AI-Powered Clinical Review: Advanced analytics systematically validate medical necessity, coding accuracy, and compliance documentation for key audit types.
- Detailed DRG & Readmission Analysis: Assess inpatient claims to verify DRG assignments, prevent inappropriate DRG readmissions, and optimize resource utilization through clinical and data-mining audits.
- Precision Itemized Bill Audits: Identify billing discrepancies, unbundled services, incorrect coding, and unnecessary charges through detailed line-item reviews, ensuring accurate payments aligned with payer policies.
- Integrated Audit Workflow: Connect seamlessly with the Alivia Case Manager™ or your claims systems and case tracking platforms via real-time API or scheduled batch processing, enhancing operational efficiency without disrupting current workflows.
ONE PLATFORM for FWA powers earlier action—stopping high-risk providers at the source and sharing insights across the claims lifecycle.
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Clinical Reviews in Payment Integrity – Knowledge Bank & FAQ
What Are Clinical Reviews in Healthcare Payment Integrity?
Clinical reviews are an essential part of payment integrity, designed to verify the appropriateness, accuracy, and medical necessity of healthcare services before or after claims are paid. These reviews go beyond coding audits by involving clinicians in the adjudication process.
Alivia’s clinical review solutions combine AI-driven pre-screening with expert clinical judgment to determine whether:
- The diagnosis supports the procedure billed
- The service was medically necessary
- Documentation aligns with payer policy or clinical guidelines
- Care was delivered at the appropriate level of service
Alivia Analytics’ Clinical Review Services
Alivia delivers a high-integrity, hybrid approach that combines:
- AI and advanced analytics to identify suspicious claims requiring clinical review
- Board-certified clinical reviewers to ensure expert evaluation of medical records
- Configurable workflows to support both pre-payment and post-payment reviews
- Peer-to-peer consultation processes for provider collaboration
- Integration with claims platforms such as QNXT™, Facets™, and HealthRules™
Key Benefits
- Reduce improper payments due to medically unnecessary services
- Comply with CMS and payer-specific policies
- Enhance audit readiness through detailed documentation and audit trails
- Prevent provider abrasion via timely peer-to-peer engagement
- Support retrospective and prospective claims validation
Frequently Asked Questions (FAQ)
What is the difference between clinical reviews and coding audits?
Coding audits check for accuracy in billing codes (e.g., CPT, ICD-10), while clinical reviews determine whether the services rendered were medically necessary and appropriately documented. Clinical reviews require clinical expertise and often involve reviewing full medical records, not just claim line items.
When should clinical reviews be applied—pre- or post-payment?
Both are valuable:
- Pre-payment clinical validation prevents improper payments before money leaves the payer.
- Post-payment clinical audits help recover overpayments and support audit readiness.
Alivia supports both approaches, depending on payer strategy and risk tolerance.
How does Alivia identify which claims require clinical review?
Using AI-powered risk models and payment integrity analytics, Alivia’s platform flags high-risk claims for clinical review based on:
- Diagnosis/procedure mismatch
- Unusual patterns by provider or region
- Services exceeding medical necessity thresholds
- Documentation inconsistencies
What types of clinical experts perform the reviews?
Alivia uses board-certified physicians, nurses, and specialists with relevant clinical backgrounds. Their expertise spans multiple specialties to ensure fair and evidence-based determinations aligned with medical policy and CMS guidelines.
Can Alivia support peer-to-peer reviews with providers?
Yes. Alivia facilitates peer-to-peer (P2P) review calls between clinical reviewers and rendering providers. This reduces denials, fosters collaboration, and helps explain determinations based on medical guidelines and documentation standards.
How do clinical reviews support CMS compliance?
Clinical reviews ensure alignment with:
- National Coverage Determinations (NCDs)
- Local Coverage Determinations (LCDs)
- Medical Necessity Requirements
- Documentation completeness for auditing
Alivia provides detailed audit logs to support CMS, OIG, and internal audit readiness.
What platforms can Alivia integrate with for clinical review workflows?
Alivia integrates with claims adjudication platforms like:
- TriZetto QNXT™
- TriZetto Facets™
- HealthEdge HealthRules™
- AMISYS
- Conduent HSP™
This allows for real-time or batched claim data routing for clinical review without disrupting core claims operations.
