The future of payment integrity
Move beyond rules engines and claims-only analytics. Alaffia’s AI Agents reason across the full clinical record, apply your policies and guidelines, and surface decision-ready findings, while clinical experts remain in control.
SMARTER CLAIMS REVIEW
Catch critical issues before and after payment
Traditional payment integrity tools rely on rigid rules that flag coding patterns without a nuanced understanding of clinical context. Alaffia’s AI platform detects potential issues before claims are paid, shifting the process from post-payment to pre-payment, while still catching what's missed upstream.
Audits that reveal more, faster
Alaffia’s AI platform cross-references each claim against coding edits, evidence-based clinical guidelines, and payer-specific policy, covering coding accuracy, medical necessity, itemized bills, and DRG classifications, to speed up processing time without losing clinical nuance.
Pre- and post-pay coverage
Pre-payment isn't the only pass. The same clinical reasoning engine reviews paid claims against the same guidelines and policy criteria to catch overpayments and errors after the fact.
Reduce review thresholds
Our AI Agents flag lower-dollar claims that would otherwise fall below a manual review threshold, so your team can expand review volume and catch savings that would normally go unreviewed.
Smart triage, real savings
Alaffia’s AI platform intelligently categorizes requests based on risk and required expertise. Straightforward cases route to fast-track approval, while complex cases route to the right clinician.
Intelligent clinical reasoning
Our AI Agents reason against medical records, policy guidelines, and relevant clinical criteria to surface smart, relevant recommendations.
Human validation
Every recommendation surfaced comes with evidence and policy citations, so that a human clinician can review, validate, and act quickly.
Scale your payment integrity team with AI Agents
More claims processed, without the added headcount. Our clinically-tailored AI Agents review coding, billing, and medical necessity, so your team can process a higher volume of claims with greater efficiency, surfacing deeper savings in the process.
DRG clinical validation
Medical necessity reviews
Readmission reviews
Short stay reviews
Itemized bill reviews
Complex claims reviews
ASC and OPPS reviews
Faster reviews, bigger recoveries
Our clinically-tailored AI Agents, paired with human validation, review itemized bills, complex claims, DRGs, clinical necessity, readmissions, ambulatory surgery center claims, and OPPS claims, finding more recoverable savings in a fraction of the time manual review takes.
Clinical chart review
We accelerate case review and uncover new savings opportunities with a structured, AI-powered workflow that reviews the full medical record against clinical criteria and policy, surfacing medical necessity, level-of-care, and readmission findings for clinicians to act on immediately.
Itemized bill review
Our team uncovers overbilling and inconsistencies with detailed line-item review across complex, ASC, and OPPS claims, matched against your health plan's coding guidelines and policies.
DRG validation
We validate DRGs quickly and accurately with AI-enabled review of coding, documentation, and diagnoses, catching upcoding, unbundling, and misclassification that rules-based tools miss.
Why leading health plans partner with Alaffia
“Alaffia opened our eyes to bigger savings and recoveries than we ever thought possible. The dollars they unlock and services they deliver are unlike anything I’ve seen from previous vendors.”
Leading Regional Health Plan
VP of Operations
“Their platform provides a level of visibility we simply didn't have before. It’s transformed how we manage our payment integrity processes across the entire organization.”
Regional Health Plan
VP of Operations
“The speed of implementation and the immediate ROI was impressive. Alaffia's team feels like an extension of our own, dedicated to our success every step of the way.”
Regional Health Plan
Head of Payment Integrity
“Alaffia is setting a new standard for how data and AI can be used to protect Medicaid resources while ensuring patients receive the care they truly need.”
US Medicaid
Dr. Andrey Ostrovsky, Former CMO
Engagements that meet you where you are
When you work with Alaffia, you get a strategic design partner and advisor that acts like an extension of your team.
Insource
Your clinical team, accelerated.
Integrate our AI platform as a core pillar of your existing workflows. Your in-house clinicians and coders review more claims, more consistently, without adding headcount.
Hybrid
Your team, plus ours.
Combine intelligent automation with in-house and outsourced clinicians to expand scale, consistency, and output.
Outsource
Your claims, our team.
No clinicians on staff? Alaffia becomes your clinical team, pairing expert reviewers with our AI’s capabilities to handle everything.
Get in touch with our team today to explore which solution is right for you.
Frequently asked questions
No. Our pre-payment reviews are designed to reduce friction, not add to it. Our AI Agents work behind the scenes to flag errors, inconsistencies, and missing documentation before a denial occurs. We also help health plans build provider education workflows where needed, so you can strengthen collaboration with your provider network over time.
Alaffia continuously monitors industry-standard code sets and integrates changes into our platform as they're released. We also track payer-specific policy updates and emerging guidance as they become available.
Alaffia's platform is designed to scale with your health plan's needs. Our AI Agents deliver a 20x increase in claims review, supporting everything from itemized bill review to complex claims reviews, giving your team room to grow without growing headcount at the same rate. Because our platform runs in parallel with your current operations, there's no limit to the number of claims we can pre-process, analyze, and flag for your clinical team.
Turn more claims into recovered savings
Discover how our clinical review platform drives real savings for your plan.
Learn more