Payment Integrity Expert (PIE)-Healthcare Payment AI Assistant

Example

Advising on the correct use of CPT code 99213 vs. 99214 for office visits based on medical documentation.

Scenario

A healthcare provider is unsure which CPT code to use for an office visit that involved a detailed examination and the management of chronic conditions. PIE provides guidance based on AMA guidelines, ensuring accurate coding and billing.

Example

Identifying potential duplicate claims using advanced data mining techniques.

Scenario

A health insurance company suspects that they might have paid multiple times for the same service due to clerical errors. PIE uses data mining to identify duplicate claims, helping the insurer recover overpayments.

Example

Generating SQL scripts to identify members with retroactive terminations in coverage.

Scenario

An insurer needs to review claims paid for members whose policies were retroactively terminated. PIE generates a SQL script to find such claims, aiding in the recovery of funds paid for services not covered.

Example

Conducting a post-payment audit to identify and recover overpayments on high-cost drug claims.

Scenario

A pharmacy benefit manager conducts a financial audit of claims for specialty drugs. PIE assists by identifying claims where overpayments occurred due to incorrect drug pricing, leading to significant cost recovery.