Delivering innovation, value and results in payment integrity services

CGI ProperPay is a holistic payment integrity solution used to identify and address claims that have been improperly priced. It’s cloud agnostic, modular-based structure is customizable to align with an organization’s strategic objectives while addressing key operational needs. In addition, its flexibility allows for integration with existing internal and external systems, providing scalability. Our solution leverages technologies such as artificial intelligence, machine learning and natural language processing in conjunction with healthcare industry expertise. Explore how CGI ProperPay is designed to protect, plan, perform, preserve, predict and prevent within the payment integrity ecosystem.

Protect

  • Data remains behind a firewall:  yours or ours

  • High level data security: ISO27001, HiTrust R2, Soc 1, Soc 2, HIPAA compliance

  • Human-centered Artificial Intelligence

Plan

  • Listen to your needs

  • Understand your environment, challenges, and goals

  • Partner for long-term strategy

Perform

  • Capture, classify, and intelligently annotate documents.

  • Ability to create and test new rules/concepts.

  • Operational workflow and insights to maximize workforce

Preserve

  • Effective communication with payers and providers

  • Achieve equilibrium within the claims payment lifecycle

Predict

  • Leverage advanced technology to identify hidden patterns and anomalies

  • Anticipate claims payment inaccuracies

Prevent
  • Using analytics and industry expert insights
  • Identify and recommend appropriate claim coding
  • Avoid rework

CGI ProperPay solution modules

Consultant working on several computer screens

Edit Studio - Rules management

A library of cognitive business rules which can be customized to payer-specific reimbursement rules and policies. CGI’s standard suite of edits has been developed and refined through more than 30 years of experience to identify the claims with the highest probability of payment errors. You have the flexibility to subscribe to any or all of our edit packages, build your own customized rules, or choose a combination of both.

Two professionals looking at a system at a desk

Audit Studio - Workflow management

Our comprehensive workflow solution allows the auditor to focus on phases of the audit process, from the screening of claims to the audit itself. The system provides reference screens for auditing guidance, grouping, and pricing to aid in efficient reviews that are defensible to the highest level of appeal. AI integration allows the auditor to access related itemized bills or medical records within the audit screen.

Woman on phone with customer

Recovery Studio - Communications management

Encouraging real-time communication between payers and providers for medical records and itemized bill requests and submissions, sharing audit findings that allow a provider to respond with agreement or appeal, and confirming which claims require pricing adjustments to be sent to the claims system for adjudication. Payers and providers can gain insights into the volume of requests, adjustments, and appeals and the timeliness of responses when accessing the studio.

Consultant working on a laptop while looking at a giant screen

AVA - AI decision intelligence

Increase audit team productivity by leveraging CGI ProperPay’s AVA, an AI decision intelligence engine that captures medical records and itemized bills into a digitally readable format, classifies into 17 document types highlighting key pieces of data and allows the user to identify specific pieces of data, through search powered by natural language processing (NLP).

Physicians reviewing data on a tablet

Claims Intelligence - Advanced data analytics

Advanced analytical techniques detect trends and patterns to identify improper payment scenarios, support concept development, select cases for review, and support staffing model optimization. CGI ProperPay combines claims data with other data sources, such as audit results, to refine targets.

Operations team working on computers at conference table

Doc Indexer - Data management

Based on defined business requirements, all applicable claims data is imported into the database, which is updated continually, allowing for a comprehensive view of the overall history and furnishing a basis for trend analysis and predictive modeling. Other data sources, such as provider and member data, are incorporated into the system to enhance analytical capabilities.

Ready to learn more about CGI ProperPay and our payment integrity solutions?

Connect with our team of expertise to learn how we leverages technologies such as artificial intelligence, machine learning and natural language processing in order to predict, prevent and recover improper payments.

500%
increase in audit efficiency through integration of AI
$3+ billion
in improper medical claims payments have been recovered for government and commercial payers
96% 
appeal uphold rate

30 years of payment integrity expertise

CGI provides innovative business and technology solutions to the healthcare payer industry. Our clear vision and ability to deliver results have made us the partner of choice for commercial health and government healthcare payers and insurers and an emerging partner for providers.

Our team of specialized industry experts has more than 30 years of experience analyzing and auditing government health plans, managed care and private insurance medical data. Our team includes clinicians, data scientists, health information management professionals, payment integrity operations specialists, claims operations specialists, and IT experts with business experience from relevant healthcare payer industries.

Business and strategy
  • Over 25 years of experience
  • Payment system conversions to prospective payment systems (weights, rates, policies)
  • Medicare payment system modeling
  • Payment integrity operations analysis & management
  • HiTrust program management
  • BlueCard operations and BCBSA compliance
Clinical
  • Physician advisors
  • RNs with average 10+ years acute care ICU experience
  • Coders with average 10+ years acute care coding experience
  • Specialty experience in:
    • Charge and iBill review
    • Behavioral health, LTAC
    • Pharmacy, Data Analytics, Business Intelligence
    • Home Health, DME
    • Medical Necessity
Support
  • U.S. based
  • Onshore support based in Troy, Alabama
Data analytics
  • Over 25 years of experience
  • General and health care specific analytics
  • Building machine learning models
Technical
  • Over 15 years of data architecture and SaaS/PaaS experience
  • Software Security Awareness training for Coding and Testing by Cigital
  • Data Architect (MIT graduate)
  • Designations:
    • Health Insurance Association of America
    • Managed Healthcare Professional
    • Health Insurance Associate