Payment Integrity
Stop the revenue leakage before it happens.
Identify, prevent, and recover improper payments with transparent, defensible controls that shift from a reactive to a proactive approach.
Overview
XBP Global’s Payment Integrity combines prepay prevention and postpay recovery, using proprietary AI-driven Data Mining to “Shift Left” from reactive mining to proactive prevention. Built on XBP’s revenue integrity scale and 30+ years of deep-domain expertise, this model leverages massive, tested claims volumes to stop improper payments at the pre-pay stage.
The solution applies policy, coding, clinical, and contract logic to flag duplicates, upcoding, unbundling, and site-of-service mismatches. High-confidence findings trigger prepay edits, while complex cases route to specialists with clear evidence. Governed, provider-aware workflows integrate with adjudication, SIU/FWA, and provider data to ensure consistent policy application.
Prepay Edits That Prevent Leakage
Apply business, coding, clinical, and contract rules to stop improper payments before they occur.
Duplicate, COB, and Frequency Controls
Detect duplicates, coordinate benefits (COB) accurately, and enforce frequency limits to avoid overpayments.
Clinical and Coding Integrity
Identify upcoding, unbundling, MUE/NCCI violations, and site‑of‑service inconsistencies with explainable logic.
Contract and Pricing Validation
Verify fee schedules, DRG/APC grouping, and contractual terms to ensure correct allowed amounts.
Targeted Postpay Recovery
Use analytics to mine paid claims for patterns of overpayment and coordination‑of‑benefits errors, launching recoveries with complete audit trails.
Appeals Management
Track overturns, root causes, and timelines to strengthen prepay logic and provider guidance.
Provider‑Friendly Resolution
Send specific, actionable reason codes and documentation requests to minimize abrasion and accelerate closure.
SIU/FWA Collaboration
Escalate suspicious patterns to special investigations (SIU) with packaged evidence and a secure chain of custody.
Compliance and Auditability
Maintain complete audit trails, role‑based access, and evidence retention to support reviews and accreditation.
Our Proprietary Tech
Predictive Data Mining Tool: Our in-house AI-driven tool that delivers predictive models using the latest concepts established by CMS to prevent improper payments.
BENEFITS
Our solution reduces improper payments through strong prepay prevention and precise recovery to drive higher net yield and sustained financial performance.
- Lower rework and provider abrasion with clear reason codes.
- Shorten resolution times using governed workflows and outreach.
- Increase policy consistency by aligning edits, pricing, and contracts.
- Strengthen compliance with full audit trails and transparent decisions.
- Adapt quickly to coding changes with configurable rules.
- Scale across lines of business with analytics‑driven operations.
Contact Us
Need help? Connect with our experts now!
Expert assistance: Our team has extensive experience in healthcare revenue cycle management and can provide knowledgeable support.
Timely solutions: We prioritize your needs and aim to resolve issues quickly.
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