Revolutionizing Payment Integrity with Pre-Payment Detection Tools

By Yoemy Waller

In today's rapidly evolving healthcare landscape, the shift from reactive post-payment audits to proactive pre-payment integrity solutions represents a fundamental transformation in how payors protect their financial interests while maintaining provider relationships.

Key Insight: Pre-payment detection systems can identify and prevent improper payments before they occur, delivering immediate ROI and reducing administrative burden on both payors and providers.

Traditional post-payment audits, while valuable, often create friction in provider relationships and require costly recoupment processes. Naviquis' pre-payment integrity solution addresses these challenges by leveraging advanced AI and machine learning algorithms to analyze claims in near real-time, identifying potential fraud, waste, and abuse before payment authorization.

2-5% Additional Savings Above Current Solutions

95%+ Accuracy Rate in Claims Analysis

$68B Annual Healthcare FWA Losses

The Naviquis Advantage: Our comprehensive solution combines precision edits, business intelligence, and automated communication tools to create a seamless payment integrity ecosystem. By identifying suspicious claims before payment, we enable payors to:

• Reduce financial losses from improper payments

• Maintain positive provider relationships through education rather than recoupment; therefore improving relationships

• Streamline claims processing workflows and reducing inefficiencies

• Ensure compliance with federal and state regulations

The integration with our Provider Relationship Management System (PRMS) ensures that when claims require attention, providers receive immediate, educational communication explaining the issues and providing guidance for future submissions. This approach transforms payment integrity from a punitive process into a collaborative partnership for improving healthcare quality and cost management.

 ARTICLE 2

Emerging Trends in Facility Claims Fraud, Waste, and Abuse

As healthcare delivery models evolve and technology advances, fraudulent schemes targeting facility claims have become increasingly sophisticated. Understanding these emerging trends is crucial for payors seeking to protect their networks and ensure appropriate utilization of healthcare resources.

Alert: Recent analysis shows a 23% increase in complex facility billing schemes involving multiple providers and sophisticated documentation manipulation techniques.

Top Emerging FWA Trends in Facility Claims:

1. Upcoding and DRG Manipulation: Facilities are increasingly using sophisticated methods to justify higher-level Diagnosis Related Group (DRG) assignments through strategic documentation timing and selective procedure bundling. This includes manipulating patient severity scores through unnecessary diagnostic procedures performed specifically to justify higher reimbursement levels.

2. Outpatient Surgery Center Schemes: The growth of ambulatory surgical centers has created new opportunities for billing irregularities, including charging for facility fees when procedures are performed in physician offices, duplicate billing for supplies and equipment, and inappropriate use of modifier codes to bypass bundling requirements.

3. Skilled Nursing Facility (SNF) Resource Utilization Groups (RUG) Gaming: SNFs are manipulating therapy minutes and patient assessment protocols to qualify for higher RUG categories, often providing unnecessary therapy services or artificially extending therapy durations to meet minimum requirements for higher reimbursement tiers.

4. Home Health and Hospice Coordination Abuse: Increasingly complex schemes involving coordination between home health agencies and hospice providers to maximize reimbursement through overlapping services, inappropriate patient eligibility determinations, and manipulation of care plan documentation.

31% Increase in Facility Billing Anomalies

$8.2B Annual Facility Claims Overpayments

Technology-Enabled Detection Strategies: Naviquis employs advanced pattern recognition algorithms specifically designed to identify these emerging trends. Our system analyzes hundreds of data points across facility claims, including:

• Comparative analysis of facility coding patterns against regional and specialty-specific benchmarks

• Real-time monitoring of Resource Utilization Group trends and outlier identification

• Cross-referencing of facility claims with provider billing patterns to identify coordinated schemes

• Advanced clinical validation to ensure medical necessity and appropriate level of care

Prevention Through Education: Beyond detection, our PRMS platform provides facility administrators with educational resources and real-time feedback on billing practices, helping to prevent inadvertent errors while identifying intentional schemes. This proactive approach has proven effective in reducing recurrence rates and improving overall compliance across facility networks.

As facility-based care continues to expand and diversify, staying ahead of evolving FWA schemes requires sophisticated technology, continuous algorithm updates, and collaborative relationships with facility partners. Naviquis remains committed to developing cutting-edge solutions that protect payor interests while supporting legitimate facility operations.

Contact Naviquis at (847) 649-5100 or email sales@naviquis.com 

Subscribe to Our Newsletter!