Caalm-ai identified contract configuration error opportunities to test payment accuracy and the relationship between a paper contract, the medical configuration system, and the paid claims.
Payment Accuracy: Contract Configuration Rules Environment
Approach
- Classified insurers by the claims processing system and built a pilot with FACETs clients, downloaded 22K+ contracts from a single insurer
- 300K contract rules were mapped to intent of payment for every hospital comparing contracts to electronic data for accuracy of coding and payments
Delivered Solution
- 100% Network Mapping: Able to map 100% of electronic contract configuration rules to less than 100 rules based on the payment methodology.
Value Generated
- Payment Integrity Vendor (1): Realizing $22M in new opportunities over first quarter, the process attributed to $200M+ in revenue across 7 clients by year three. 88% of processes was automated saving the equivalent of 15 full-time employees and achieving 92.6% accuracy rate.
- Payment Integrity Vendor (2): Partnering with Lorica Healthcare to adapt their contract analytics and a contract negotiation UI to create a new contract monitoring and surveillance product; leading to $5M in semi-automated MVP revenue to create a new international market ready product.
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