Payment Integrity Audits: Case Study Scenarios With Potential Impacts

Case Study Scenarios With Potential Impacts

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Recover Missed Overpayments from Legacy Vendor Gaps

SCENARIO:

A regional health plan serving 1.2 million members seeks a more effective alternative after discovering inconsistent recoveries from its legacy payment integrity vendor.

  • Challenge: Low recovery rates and limited transparency from the incumbent vendor.
  • Solution: Alivia can implement a comprehensive audit suite featuring enhanced anomaly detection and AI-supported pre-payment edits.

Reduce Vendor Dependence & Improve Operational Control

SCENARIO:

A national payer aims to reduce long-term vendor reliance and gain greater internal oversight of post-payment audit functions.

  • Challenge: High vendor fees, slow recovery timelines, and lack of visibility into audit processes.
  • Solution: With Alivia experts and the Alivia 360™ platform, internal teams can streamline audits, boost accuracy, and reduce vendor reliance.

Detect High-Risk Claims Before Payment is Issued

SCENARIO:

A Medicaid managed care organization seeks to proactively prevent losses from upcoding, COB errors, and emerging fraud risks.

  • Challenge: Overreliance on post-pay audits and rising improper payment costs.
  • Solution: Alivia’s pre-payment edits and clinical logic can identify high-risk claims early in the adjudication process.

Expand Audit Coverage Without Scaling Staff

SCENARIO:

A midsize health plan needs to expand audit operations but lacks the internal staff to support growing claim volumes.

  • Challenge: Resource constraints limit the scope and speed of both clinical and non-clinical audits.
  • Solution: Alivia can provide a hybrid model combining outsourced expertise with AI-driven tools to enhance throughput and efficiency.