AArete Payment Intelligence® goes beyond the simple payment policies approach used by payment integrity vendors. We identify claims recovery opportunities, as well as configuration analytics, to address errors around member eligibility, covered benefits, contracts, provider data, payment policies, and prior authorizations.

Yes, Payment Intelligence® can provide you with transparency into the accuracy of your provider data. With the No Surprises Act requirements, we know this is an area of concern. We validate and verify that configured information matches source documents, including provider-sourced information (such as rosters, ACT files, contracts) and third-party information (such as AArete market intelligence, NPPES, etc.).

If not carefully managed, artificial intelligence can provide a lot of false positives. Our Payment Intelligence® process relies on machine learning to ensure that findings continue to improve when presented and prepared for each client. This helps to ensure any manual reviews conducted by your team are minimized over time to reflect just the changes with the highest probability of acceptance.

Payment accuracy goes beyond claims editing.  Inaccurate configuration setups are a leading cause of mispaid claims. Antiquated systems, manual processes, lack of communication, insufficient training, and poor-quality assurance all contribute to this persistent problem. Achieving true payment accuracy requires a more holistic approach to address the systems configuration issues that lead to mispaid claims, including provider participation data, contracted rates, covered benefits, and prior authorizations. We are the only solution in the market that takes this holistic approach. By leveraging insights from physician rosters, provider contracts, benefits grids, and prior authorization details, we are able to identify the root cause and resolve the configuration setup issues, enabling the system to process payments right the first time. 

Payment Intelligence® complements its rules-based analytics with AI-based data science models. AI is great at predicting anomalies in delivery of care (e.g., procedures, units, site of service, specialty) and in payment (e.g., participation, rates). Not all that AI identifies is actionable. While other vendors offer AI-based services, Payment Intelligence® focuses on only presenting actionable findings to our clients, adapted to correspond to each client’s appetite for opportunities and capacity to review our findings.

In addition, AArete has incorporated AI into its proprietary tool, Doczy.ai™ which utilizes optical character recognition (OCR) technology, natural language processing (NLP) and large language models (LLM), combined with AArete’s proprietary approach to tune for the client-specific nuances of provider contracts. Doczy.ai™ assists AArete’s provider contract subject matter experts to expedite the consumption of large volumes of unstructured data from provider contracts (e.g., reimbursement methodologies, “lesser of” language, payment hierarchy, unlisted codes, complex carve-outs, and other source information) and to deliver structured output that can be leveraged for a variety of beneficial purposes, including the identification of misconfigured provider contracts to be corrected in the system and the resulting mispaid claims.

AArete’s process to minimize false positives has been honed across many client projects, resolving the issues driving their claims payment inaccuracies. By bundling our market intelligence and subject matter expertise with machine learning, we provide you with Payment Intelligence® results that minimize false positives.

AArete Payment Intelligence® was built and is managed by a team of seasoned payment integrity and payment accuracy professionals. Our goal is always to prevent future occurrences of errors by going deeper to understand the root cause of issues. We identify the people, process, data, or technology for the appropriate fix. We work closely with our clients to ensure our recommendations are actionable and effectively resolve the payment error on future claims. 

Our rapid onboarding process can have clients testing and validating findings within 30 days of the claims data upload, delivering a quick ROI.  We use your company policies and contractual obligations to build in quality and continuously test and fine-tune to serve clients with ongoing presentation of recoupable findings, insights into optimization, and root cause remediation.