Stop Fraud Before It Costs You.
Payment Integrity
Our AI-powered pre-payment engine analyzes every claim before a dollar leaves your system. Real-time FWA detection across 68,000+ diagnosis and procedure codes -- with built-in provider education so the process builds trust instead of burning it.
The Problem
Fraud Does Not Wait for Your Next Audit
Most payers catch improper payments after the money is gone. Post-pay recovery is expensive, slow, and rarely complete. The damage to provider relationships and plan margins compounds every quarter it goes unchecked.
Traditional claims editing tools flag obvious errors. They miss sophisticated fraud patterns, duplicate schemes, and improper coding combinations that span thousands of diagnosis codes.
3-10% of Claims Paid Are Improper
Industry estimates place improper payments between 3 and 10 percent of total claims spend. For a mid-size payer, that is millions leaving the system every year.
Post-Pay Recovery Is a Losing Game
Chasing paid claims costs more than it recovers. Provider disputes, administrative load, and damaged relationships eat into every dollar you do get back.
Legacy Tools Miss What Matters Most
Rules-based editing catches simple errors. It was not built to detect coordinated fraud schemes or complex coding combinations across 68,000 diagnosis and procedure codes.
How It Works
Stop Fraud Before a Dollar Leaves
Our AI engine runs after adjudication but before payment authorization. Every claim gets analyzed in real time, without slowing your existing process down.
Step 1 · Ingest
Claim Enters the Queue
Every submitted claim flows into the Naviquis engine immediately after your standard adjudication process clears it.
No manual uploads. No batch delays. Real time.
Step 2 · Analyze
AI Runs the Analysis
The model cross-references the claim against 68,000+ diagnosis and procedure codes, historical billing patterns, and known fraud schemes.
Medical and dental claims. Both covered.
Step 3 · Flag
Suspicious Claims Are Held
Flagged claims are held before payment authorization. Your team reviews the alert with full context: reason code, supporting data, and recommended action.
Legitimate claims pass through without delay.
Step 4 · Educate
Provider Gets the Full Picture
A detailed denial explanation goes directly to the provider. They learn what was flagged, why it was flagged, and how to correct and resubmit accurately.
Trust builds. Abrasion drops. Accuracy improves.
What We Deliver
Built to Catch What Others Miss
Every capability in our Payment Integrity platform was designed around one goal: stop improper payments before they leave your system.
Real-Time Pre-Payment Analysis
Every claim is analyzed after adjudication and before payment authorization. No bottlenecks. No batch windows. No dollars lost while you wait.
FWA Detection Across All Claim Types
Medical and dental claims are both covered. The model detects fraud, waste, and abuse patterns across improper coding, duplicate billing, and unbundling schemes.
68,000+ Diagnosis and Procedure Codes
The model covers the full ICD and CPT code spectrum. Combinations that look fine in isolation but signal fraud in context get flagged every time.
Built-In Provider Education Loop
Every denial includes a plain-language explanation for the provider. They understand what was flagged and how to correct it. Abrasion drops. Accuracy improves over time.
Integrates With Your Existing Stack
No rip-and-replace. Naviquis connects to your claims editing solution, adjudication system, and data sources via secure API. You keep what works.
Post-Adjudication Reporting and Audit Trail
Every flagged claim is logged with full decision context. Your compliance team gets a clean audit trail and the reporting data to demonstrate ROI at every review cycle.
By the Numbers
Results That Show Up on the Balance Sheet
Payment integrity done right is not a cost center. It is one of the highest-ROI investments a payer can make.
3-10%
Of Claims Spend Lost to Improper Payments
Industry average across commercial payers and health plans
68K+
Diagnosis and Procedure Codes Covered
Full ICD and CPT spectrum analyzed on every single claim
Pre-Pay
Stop It Before It Leaves Your System
Post-pay recovery costs more than it returns. Prevention is the only model that works.
Weeks
Average Time From Kickoff to Live
We build on your existing infrastructure so there is no long onboarding timeline to sit through
Get Started
See What Naviquis Catches Before You Pay
We will walk you through a live analysis using claims data from your environment. No generic demo. No pressure. Just a clear picture of what the AI finds and what it saves.