Case Study: Medical Overpayment Protection

Medical Overpayment Protection Case Study: Charges For Non-Rendered Services

Alaffia Health’s team utilizes an advanced AI-driven platform for medical overpayment protection to identify, prevent, and recover overpayments made by healthcare payers. Our fusion of advanced technology and subject expertise saves partner organizations an estimated $150 per member per year (for a plan with 100k members and a partnership with Alaffia.) 

Fraud, waste, and abuse costs healthcare payers an estimated $300 billion each year. Alaffia Health provides an immediate impact to your bottom line with a turnkey solution that integrates with existing systems to identify and prevent unnecessary overpayments. Here’;s one example of how Alaffia saves money for their partners every day.

 The Situation: 

Our proven team of medical overpayment protection analysts leveraged Alaffia’s AI-driven platform to review a claim for services rendered in May 2019. The claim totaled $48,706.58 for all services billed to the payer. Revenue code 250 (pharmacy charges) made up the bulk of the claim. 159 units were billed totaling $33,994.07. 

The itemized bill showed 100 units of Alteplase on 4/29, totaling $33,444. With over 68% of the total charges falling under a single revenue code, Alaffia’s advanced platform indicated a need for a higher level review. 

Alaffia’s platform and highly skilled medical overpayment protection analysts considered several components of the claim during their forensic review. As noted In the documentation, the physician determined that the patient was out of the effective time window for the medication to be effective and chose not to administer it. However, the provider still billed the medication to the healthcare payer. 

medical overpayment protection documentation

Our Results:

The initial claim totaled $48,706.58, including $33,994.07 in pharmacy charges (revenue code 250.)

Alaffia identified overpayments for this claim of: $33,344.00.

The new charge amount for revenue code 250 after Alaffia’s review is: $650.07

We reduced the amount of this claim to: $15,362.58

Alaffia’s AI-driven platform automatically flags high-cost claims for review by medical overpayment protection analysts and requests supporting documentation. This allows analysts to focus on claims more likely to contain discrepant charges. 

We leverage the force multiplier of AI-driven workflow automation and the expertise of billing, coding, and clinical analysts to achieve extraordinary results like this every single day. Set up a call and learn how you can put Alaffia’s capabilities to work for you. 

Highlights: 

  • Alaffia detects and prevents unnecessary overpayments before they’re made.
  • Our platform seamlessly integrates into your existing systems with no disruptions and immediate results. 
  • AI technology allows us to audit more claims, resulting in industry-leading recoveries.
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