Clinical Reviews for Claims Payment Integrity

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Clinical Reviews

Expert clinical and coding auditors lead our tech-enabled services. They leverage Alivia’s powerful, configurable Payer Analytics Platform to conduct post-payment reviews, or to flag and pause suspect claims in real-time, requesting medical records from providers for a thorough review. This system is ideal for placing specific providers under pre-payment review following a post-payment fraud investigation or scrutinizing certain claims or service types, on pre- or post-payment basis. Alivia’s team assesses claims to determine the appropriate action – denial, adjustment, or original billing – and post-payment recovery approach.

Focus Areas:

  • DRG Coding Accuracy
  • Compliance With Coding Guidelines
  • Documentation Adequacy
  • Medical Necessity
  • Quality Management System
  • Compliance Title 21-CFR Part 820
  • Device Classifications & Listings
  • Charge Accuracy
  • Itemization & Transparency

Examples of Clinical reviews

Clinical Chart Auditing (Billed Charges/% of Billed)

Comprehensive review and assessment of medical records to ensure accuracy, completeness, compliance with regulations, and quality of care provided to patients.

Diagnosis-Related Group (DRG) Audit

Detailed examination of medical records and coding practices to ensure accurate assignment of DRGs.​

FDA Implant Audit ​

Compliance with regulatory requirements related to medical implant billings.​

Itemized Bill Audit​

Verification of the accuracy and completeness of charges billed for medical services provided to a patient.​

Team of experts

Clinical Auditors RN, LPN Licensed medical review experts

Coding Auditors CCS, CIC, CPC Certified coding review experts

Quickly identified and confirmed fraud and payment issues.”

AI ASSIST FUNCTIONS

Alivia’s AI capabilities extend beyond traditional data analysis, providing predictive modeling, real-time decision support, and automated workflows that enhance operational effectiveness. By leveraging AI, we help organizations avoid fraud, optimize their payment processes, and confidently make data-driven decisions.

Alivia Healthcare LLMs

Revolutionize Healthcare Data Management with our advanced AI-powered Large Language Models (LLMs) to unlock unstructured data and drive actionable insights.
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