Anomalies are abundant. Enforceable findings are not.
Any analytics tool can flag what looks unusual. The hard part is knowing which findings will hold up against your contracts, your payment policies, and the rules you pay under, and which will only burden reviewers and providers. Every false positive costs reviewer time and provider goodwill, and in a thin network, providers who leave take access with them. That judgment comes from people who have run payment integrity at national health plans. Conciencia builds it in.
How Conciencia works
- Rules and AI together Payment-policy and claims-edit rules run alongside AI that looks for what rules miss: upcoding, unbundling, sudden shifts in billing behavior, and aberrant practice patterns.
- Fraud, waste, and abuse Surface suspicious billing patterns and the evidence behind them. Your team decides whether to correct the problem, investigate further, or do both.
- Complex, high-dollar claims Speed the review of the claims where a single error costs the most.
- New rules from validated patterns When reviewers confirm a pattern, it becomes a rule, so the next occurrence is caught automatically.
- Root cause Trace improper payments to their source, whether a configuration, a policy gap, or a provider practice, so they are fixed once instead of recovered every year.
Every finding shows its reason, its evidence, and what it is worth.
Keep the finding and the result distinct
- Detected pattern A claim, provider, or pattern warrants examination.
- Validated finding Review establishes an issue within the defined payment and clinical context.
- Operational response The authorized team decides whether correction, recovery, or another action is appropriate.
- Financial result Recovered and prospectively avoided amounts are measured separately from suspected opportunity.
Each finding strengthens the next.
Cogitativo’s team reviews root causes, impact, and remediation options with your team, so the people responsible can choose the appropriate response. Assess whether the problem recurs and how billing behavior changes after action is taken. Over time, your organization builds an inventory of payment vulnerabilities, actions taken, and results that informs the next decision.
Evaluate usefulness, not alert volume
A useful payment-integrity evaluation shows what survives review, what overlaps with existing controls, and how much work the findings create. It distinguishes gross identified opportunity from validated financial impact. Define those measures at the start. A larger queue is not, on its own, evidence of a better result.
Begin with the claims question you need to answer
Tell us the claim population, the payment problem, the information available, and how your review process works. We'll define the Conciencia scope and how its contribution will be measured.
Discuss Conciencia