The Challenge
This payer’s Financial Risk Management department was only able to audit 10% of the 130,000 invoices it received annually due to the exceptional manual burden of the process. However, this practice put them at risk for overpayments due to fraud and errors.
The Solution
Amitech, a Naviant Company, partnered with this healthcare payer to implement an intelligent system that integrates optical character recognition (OCR) for digitization, connects with existing databases, and applies predefined validation rules. The system uses machine learning for complex code interpretation, automatically approves or denies based on results, generates detailed reports, and interfaces with payment systems. This solution ensures complete audit coverage, reduces errors, and avoids millions in overpayments while maintaining compliance.
Implementation
The process for implementation is as follows:
- Outlook: Invoices received from 3rd party vendors and other insurance plans for auditing of pre- and post-payment amounts.
- Database (EDWARD): A bot queries the database to extract member and group details.
- Blue2: The invoice is validated based on predefined rules for pre- & post-pay amounts. The amount is approved or denied based on the result.
- Report Generated: A report is then generated for routing back to the vendor.
