Ensure Appropriate Reimbursement for Every Claim
Specialty reviews are inherently complex, emphasizing the importance of maintaining payment accuracy and ensuring appropriate reimbursement. Apixio’s advanced technology addresses key areas such as high-cost drugs claims, readmissions, hospital bill audits, and place of service determinations. By leveraging our AI-enabled SaaS platform, health plans can simplify these complex reviews, ensuring accuracy and compliance. Our solutions not only enhance the efficiency of these reviews but also provide significant cost savings and reduce the likelihood of reimbursement errors.
Faster, Simplified Specialty Review Workflows
Repeatable, Accurate Review Results
Lower Provider Appeal Rates for Denied Claims
Specialty Reviews
High-Cost Drugs
High-cost drugs remain a significant expenditure, and their complexity can result in billing inaccuracies.
Our solution addresses the rising expenses of injectable and oral drugs under the Medical Benefit in both inpatient and outpatient settings. By integrating a contextual processing engine, we achieve average savings of $3-4 PMPM.
Our solution addresses the rising expenses of injectable and oral drugs under the Medical Benefit in both inpatient and outpatient settings. By integrating a contextual processing engine, we achieve average savings of $3-4 PMPM.
Readmissions
Readmission of a patient following hospitalization is a costly and often preventable event.
Using diagnostic and DRG criteria, our platform detects readmissions within 30 days of discharge, including same-day readmissions, which are often the most challenging to capture and address. This results in $3-4K savings per claim.
Using diagnostic and DRG criteria, our platform detects readmissions within 30 days of discharge, including same-day readmissions, which are often the most challenging to capture and address. This results in $3-4K savings per claim.
Hospital Bill Audit
Auditing medical bills with various contractual agreements can be challenging, requiring identification, monitoring, and correction of inappropriate billing practices.
Our natural language processing (NLP) technology meticulously reviews hospital billing to ensure accuracy and compliance with contractual agreements between healthcare providers and payers.
Our natural language processing (NLP) technology meticulously reviews hospital billing to ensure accuracy and compliance with contractual agreements between healthcare providers and payers.
Place of Service
Determining whether care should be inpatient or outpatient can have significant financial implications.
Apixio’s algorithms evaluate the site of care related to a claim, identifying inappropriate care settings. Our technology reviews claims to ensure correct billing as inpatient or outpatient, leveraging the Two-Midnight Rule and other references to minimize reimbursement errors.
Apixio’s algorithms evaluate the site of care related to a claim, identifying inappropriate care settings. Our technology reviews claims to ensure correct billing as inpatient or outpatient, leveraging the Two-Midnight Rule and other references to minimize reimbursement errors.
Features
Advanced analytics engine identifies claims with high recovery probability
OCR processing and NLP data extractions streamline claim determinations
Real-time error detection with client-configurable rules engine
Client-specific content libraries
Efficient workflow routing based on specific claim pendency reasons
Transparent claim status insights, reports, and data analytics
Featured Resources
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