PAYMENT INTEGRITY
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.
Potential Impact:
Health plans may recover tens of millions in missed overpayments annually and realize a measurable increase in audit yield compared to legacy vendors.
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.
Potential Impact:
Potential Impact: Organizations could reduce vendor-related overhead by up to 40% and improve recovery timelines by 30–40%, while maintaining full compliance and control.
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.
Potential Impact:
Health plans may prevent millions in improper payments within the first two quarters and significantly reduce downstream audit volume.
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.
Potential Impact:
Plans could triple their audit volume and increase recovery per audit hour by up to 60%, all without adding internal headcount.