Unmatched Innovation: Leverage AI-driven payment
integrity for precision in pre-pay and post-pay analysis.
The Gynisus of Payers:
Why Us?
Flexible & Comprehensive: Begin with automated DRG
and NCCI implementation, expanding seamlessly to clinical
integrity, medical necessity, and beyond—our holistic
solution grows with your evolving goals and needs.
The Gynisus of Payers:
Why Us?
Designed by doctors, for doctors, and now leveraged by
payers:
SPAI prioritizes clinical precision over generic trends for
superior payment integrity, bringing clinical accuracy and
real-time insights to payers for effective waste and error
prevention.
The Gynisus of Payers:
Why Us?
Proven Results: Realize significant savings beyond
traditional FWA solutions.
The Gynisus of Payers:
Why Us?
Seamless Alignment and Integration: Integrate
effortlessly with your operations, maximizing savings and
efficiency.
The Gynisus of Payers:
Why Us?
Superior Detection: Identify FWA and errors
effectively with a bias-resistant, data-driven approach.
Optimize Accuracy, Maximize Savings: Transform Your DRG
Processes and Operations with Intelligent Automation, Equipped
with Detailed Rationale to Minimize Appeals
Level 1- DRG assignment accuracy
SPAI’s advanced DRG model reviews claim data as submitted,
identifying inaccuracies in DRG assignments based on
industry grouping methodologies. It automatically adjusts to
the correct DRG when discrepancies are found.
Example:
The following claim was received in postpay, where the
health plan had paid for APR DRG 9513. However, the correct
APR DRG is 3443; therefore, SPAI PI flagged the claim and
corrected the DRG automatically.
Level 2 - Coding Guideline Adherence
SPAI delves into the medical coding within claims to
identify discrepancies with clinical and coding guidelines.
It then corrects these errors, ensuring alignment with the
appropriate DRG.
Advanced: Pdx Appropriateness
With our advanced capabilities, SPAI uses a multi-modal
approach, integrating claims data with clinical insights to
assess relationships between conditions and procedures. It
identifies instances where the primary diagnosis may not
accurately reflect the patient's reason for the visit.
Example:
A postpay claim in which the health plan had paid for APR
DRG 2633 was reviewed. After a detailed analysis using the
SPAI PI multimodal process to assess Pdx appropriateness,
the recommendation was to modify the Principal Diagnosis
(Pdx) from K85.10 to K80.00, thereby changing the APR DRG to
3443.
Clinical Validation (DRG Level):
With our advanced capabilities, SPAI uses a multi-modal
approach, integrating claims data with clinical insights to
assess relationships between conditions and procedures. It
identifies
Example:
A postpay claim for APR DRG 470 (Hip Replacement) was
reviewed using the SPAI PI pipeline. The claim lacked CPT or
revenue codes for preoperative imaging and ICD-10 codes
supporting the necessity of the surgery. Due to insufficient
supporting codes, the claim was flagged for regrouping and
further review.
Deliverables:
SPAI provides claim-level and line-level flags, offering
suggested DRG changes along with detailed explanations.
Data Inputs:
Claims data only—no additional history required.
Automated Coding Editing
Our Enhanced National Correct Coding Initiative (NCCI) Editing
solution takes automation to the next level, streamlining every
step from PTP editing validation to MUE and AOC checks. Powered
by advanced automated technology, it delivers fast, precise, and
reliable results, ensuring unmatched speed, accuracy, and
consistency across the board.
Example:
A claim including codes 99213-25, 17110-XU, 17000-XU, and 17003
was flagged by SPAI PI for the line with code 17110-XU due to an
NCCI PTP edit. Per guidelines, overlapping services on the same
site cannot be billed together.
Deliverables:
SPAI provides claim-level and line-level flags, offering
suggested DRG changes along with detailed explanations.
Data Inputs:
Claims data only—no additional history required.
Clinical Integrity
Uncover Opportunities and Savings Driven by Clinical Integrity
and Medical Necessity
Using our multi-modal pipeline, which utilizes claims data and
clinical understanding to evaluate the relationships between all
conditions and procedures, then applies its experience and
clinical rationale to identify discrepancies and opportunities.
Promote Evidence Based Reporting
Our solution meticulously identifies any discrepancies or
contradictions between incoming claims and a patient’s
clinical condition or the actual occurrences during their
visit. By ensuring that claims align with established clinical
and medical coding guidelines, as well as industry standards
and best practices, we help prevent inaccuracies that could
lead to overpayments or denials, fostering compliance and
precision in claim submissions.
We leverage a powerful multi-modal pipeline to evaluate each
case, combining claims data with deep clinical understanding.
This advanced approach analyzes the relationships between all
conditions and procedures, applying clinical expertise and
rationale to pinpoint areas of discrepancy. The result is a
thorough and accurate review process that identifies
inconsistencies and supports more effective, evidence-based
claim handling.
Example:Claim Number: XXXXX Claim Paid Amount: $15,988.12 Gynisus Recommendation: Medical
Record Review Rationale:
Oligohydramnios (code O41.03X0) was reported alongside the
drainage of water (code 10E0XZZ), which presents a
contradictory indication. Hence, we recommend querying the
provider for clarification.
Claim reports Oligohydramnios (code O41.03X0) alongside the
drainage of water (code 10E0XZZ).
This presents a contradictory indication between the
condition and the procedure reported.
SPAI identifies and flags wasteful patterns, providing
detailed claim information and explanations for each
identified finding, allowing for targeted action.
Deliverables:
SPAI provides claim-level and line-level flags, offering
suggested DRG changes along with detailed explanations.
Data Inputs:
Claims data, plus optional claims history, Rx, labs, vitals.
MEDICAL NECESSITY
Clinical Pattern Recognition
Description:
Identify patterns of clinical waste at the provider level
related to Medical Necessity, pinpointing opportunities to
eliminate unnecessary and unreasonable tests, equipment,
services and procedures. This analysis helps reduce costs by
focusing on areas where areas of opportunity exist to reduce
unnecessary orders.
Deliverables:
SPAI identifies and flags wasteful patterns, providing
detailed claim information and explanations for each
identified finding, allowing for targeted action.
Example:Claim number: XXXX Claim Paid Amount: $35,823.91 Gynisus Recommendation: Medical
Record Review
In the following claim, the patient presented to the clinic
with right foot drop, other specified soft tissue disorders,
and abnormal levels of other serum enzymes. Multiple
overlapping tests were conducted to determine the source of
the foot drop; however, the necessity of these numerous
radiology tests is unclear and requires verification with the
provider. Additionally, most of the reported tests do not
align with certain documented findings.
352 Revenue code_CT Scan - Body_CT Scan - Body Scan
72148 Diagnostic Radiology (Diagnostic Imaging) Procedures
of the Spine and Pelvis
73610 Diagnostic Radiology (Diagnostic Imaging) Procedures
of the Lower Extremities
73630 Diagnostic Radiology (Diagnostic Imaging) Procedures
of the Lower Extremities
73706 Diagnostic Radiology (Diagnostic Imaging) Procedures
of the Lower Extremities
73721 Diagnostic Radiology (Diagnostic Imaging) Procedures
of the Lower Extremities
Deliverables:
SPAI provides claim-level and line-level flags, offering
suggested DRG changes along with detailed explanations.
Data Inputs:
Claims data only—no additional history required.
Fraud, Waste, and Abuse (FWA) Detection: Empower Your SIU Team
Leverage cutting-edge AI to identify and investigate
questionable behavior patterns among providers and
patients. Seamlessly integrate with other SPAI solutions,
providing a holistic view of FWA activities.
SPAI PI equips your SIU team with precise, actionable
insights and pre-prepared evidence, enabling you to detect
and resolve potential FWA efficiently, minimizing your
team’s workload while safeguarding your financial
resources.
Lead Generation + Case Validation: Receive comprehensive
reports detailing concerning patterns, complete with all
claim information, evidence, and explanations. Our
solution prepares validated findings for your SIU team, so
minimal to no additional efforts are needed for further
investigation.
Example:Claim number: XXXX Claim Paid Amount: $30,798.47 Gynisus Recommendation: Medical
Record Review Rationale:
Specific Claim: In the following
claim, the provider reported sepsis (unspecified), acute
appendicitis, and a procedure of resection of the appendix via
a percutaneous endoscopic approach. Lab tests were conducted,
but there is no report identifying the specific organism, nor
is there alignment with sepsis criteria. Additionally, oral
antibiotics were administered, which may indicate an attempt
to prevent sepsis, though sepsis was not confirmed. The
severity of illness was reported as level 3. We recommend
querying the provider for evidence supporting the sepsis
diagnosis.
Zoom Out:
The provider handling the above claim managed 19 cases of
acute appendicitis with perforation and localized peritonitis
(without abscess), performing resection of the appendix via a
percutaneous endoscopic approach. In each case, unspecified
sepsis was reported, and lab tests were conducted without
identifying a specific organism, nor is there alignment with
sepsis criteria. Oral antibiotics were administered,
potentially as a preventative measure against sepsis; however,
no specific evidence of sepsis was documented. Patients were
hospitalized for a uniform duration of exactly 96 hours, and
the Severity of Illness (SOI) was reported as level 3 across
all cases.
Deliverables:
AI-driven detection of FWA with actionable insights, evidence,
and seamless integration for comprehensive SIU support.
Detailed reports highlight questionable patterns, enabling
efficient case resolution with minimal additional
investigation.
Data Inputs:
Claims data + optional: Rx, labs, vitals, and MR.
SPAI PI MRR - A Complete Solution for Automated Medical Record
Retrieval and Review
Effortlessly connect with any provider on Epic or Cerner and
automatically retrieve medical records, streamlining your entire
review process.
Enhance the efficiency and accuracy of your medical record
reviews with SPAI PI’s advanced capabilities:
Unbiased Review (DRG Validation, Clinical Validation,
FWA, Medical Necessity):
Utilize cutting-edge AI for precise, objective medical
record analysis across a wide range of use cases, ensuring
compliance and accuracy.
Comprehensive Review Reports:
SPAI PI generates detailed review reports, using our
proprietary and sophisticated technology to identify
unsupported medical codes, conditions, and procedures in
clinician notes. This thorough analysis helps pinpoint
areas that require attention, enhancing the quality and
accuracy of your reviews.
Validation Service:
For an added layer of assurance, we offer an optional
validation service, where our team of prestigious
doctors—each with over 30 years of experience—reviews the
MRR. This service ensures that every assessment meets the
highest standards of clinical accuracy and integrity.
Experience a seamless, end-to-end solution for automated
medical record retrieval and review with SPAI PI, designed to
elevate your efficiency and results.
View Attachment
Deliverables:
Automated medical record retrieval and unbiased review reports
with advanced AI for DRG validation, clinical validation, FWA,
and medical necessity. Comprehensive analysis identifies
unsupported codes and procedures, enhancing review accuracy
and compliance.
Data Inputs:
Medical Record
Ready to See the Difference?
Experience the power of SPAI PI platform today. Contact Gynisus for an
immediate demo and seamless integration.
Let’s transform your payment integrity process together!
