Payment Integrity: Smarter Oversight Beyond Coding Edits
How Avalon’s lab-specific payment integrity rules identify improper claims and prevent waste in real time.
Avalon’s Approach
Avalon replaces static coding edits and retrospective audits with dynamic, science-informed payment integrity.
- Integrates lab-specific rules to catch inappropriate claims before payment
- Applies policy-driven intelligence post-service and pre-payment to reduce waste and abuse
- Validates claims against adopted policies to ensure appropriate utilization
- Prevents improper payments that traditional coding-based systems often miss
By combining real-time rules with science-backed policy validation, Avalon helps payers reduce inappropriate spend and protect value.
Proven Impact
A commercial plan flagged recurring overuse of bundled lab panels. Avalon’s post-service, pre-payment Payment Integrity engine isolated the root issue—overlapping tests billed under general CPT codes.
Key Capabilities Used
- Claims-Level Test Validation
- Post-Service, Pre-Payment Edit Automation & Policy Enforcement
- Science-based Rules for Routine & Genetic Testing
Impact
- 10–20% reduction in inappropriate lab spend
- Enhanced FWA detection beyond standard code audits
- Simplified contracting and oversight