Alaffia Health is an AI-driven medical claims review platform that helps health plans and third-party administrators (TPAs) reduce claim errors, identify fraud and waste, and improve overall cost containment. By using machine learning and natural language processing, Alaffia reviews healthcare claims at scale with clinical and financial accuracy, transforming how payers process and adjudicate claims.
The platform replaces slow, manual auditing processes with automated, real-time analysis that detects improper billing, coding inaccuracies, and medically unnecessary services. Alaffia empowers payers to recover overpayments, minimize provider abrasion, and improve operational efficiency, while ensuring fair and accurate reimbursement.
With rising costs and administrative complexities in the healthcare system, Alaffia Health offers a next-generation approach to claims integrity and payment accuracy.
Features
Alaffia Health delivers a robust set of features designed to streamline and enhance medical claims review processes.
AI-Powered Claims Review
Automates post-pay and pre-pay medical claim audits using machine learning and clinical rulesets.
Natural Language Processing
Interprets and extracts context from clinical documentation to verify medical necessity and identify inconsistencies.
Real-Time Payment Integrity
Performs claim validation during adjudication or shortly afterward to maximize savings and minimize rework.
Customizable Rules Engine
Allows payers to tailor audit logic to specific plan designs, coverage rules, and medical policies.
Clinical Documentation Analysis
Reviews supporting records such as medical notes and treatment histories to validate claim submissions.
Fraud, Waste, and Abuse Detection
Identifies upcoding, unbundling, phantom billing, and other suspicious patterns that signal improper billing.
Claim Scoring and Prioritization
Ranks claims based on likelihood of error or financial impact, allowing auditors to focus on high-value reviews.
Audit Trail and Reporting
Provides detailed reasoning and data trails for each flagged claim, supporting appeals and compliance audits.
Seamless Workflow Integration
Integrates with payer systems through APIs to embed into existing adjudication and payment workflows.
Security and Compliance
Built on HIPAA-compliant infrastructure with secure, auditable access and robust data privacy protocols.
How It Works
Alaffia Health connects to a health plan’s claims data either directly through a secure API or batch file transfer. Once claims data is received, the platform processes each claim through a series of AI models and rules-based engines.
Natural language processing is used to extract relevant information from clinical notes, diagnoses, and procedure codes. This allows Alaffia to detect discrepancies between what was billed and what was actually documented. For example, if a claim indicates a high-acuity procedure but the clinical notes suggest routine care, the platform flags the claim for review.
Each claim is scored based on risk and cost exposure. High-risk claims are prioritized for manual audit or further documentation review, while low-risk claims can be auto-cleared. Alaffia provides a clear rationale for every flagged claim, giving payers transparency in decision-making.
The system continuously learns from historical claim outcomes and audit decisions, improving accuracy and reducing false positives over time.
Use Cases
Alaffia Health serves a variety of needs for payers, TPAs, and organizations responsible for healthcare cost containment.
Post-Pay Medical Claims Audit
Identify improper payments after adjudication to recover overpaid funds and reduce financial leakage.
Pre-Pay Claims Validation
Review high-risk claims before payment to prevent costly errors from entering the system.
Fraud, Waste, and Abuse Programs
Support SIU (Special Investigation Units) with automated detection of billing anomalies and fraud triggers.
Clinical Documentation Review
Analyze associated records to verify that services billed match the clinical documentation.
Provider Network Oversight
Monitor claim trends across providers to detect patterns of abusive billing or coding practices.
Specialty Claim Categories
Audit high-cost areas such as orthopedic surgery, oncology, cardiology, and behavioral health.
TPA Operational Efficiency
Enable third-party administrators to scale audit programs without expanding headcount.
Pricing
Alaffia Health does not list public pricing on its website, as its platform is typically implemented on a customized, enterprise basis.
Pricing depends on factors such as claims volume, audit scope, integration requirements, and client-specific rulesets. Interested payers and TPAs can request a tailored proposal and demo through the Alaffia Health contact page.
The solution is best suited for mid-size to large health plans, self-funded employer groups, and TPAs managing significant claims throughput.
Strengths
AI-driven platform reduces manual work and increases audit efficiency.
Improves claims accuracy and ensures appropriate use of plan resources.
Detects fraud and abuse patterns using advanced machine learning and NLP.
Integrates with payer workflows to enable real-time or near real-time validation.
Supports both pre-pay and post-pay claim reviews.
Transparent claim scoring and audit trail support compliance and appeals.
Continuous model learning improves performance over time.
Flexible to accommodate custom medical policies and plan rules.
HIPAA-compliant and built for enterprise-grade security.
Drawbacks
Not suited for small practices or organizations with low claims volume.
Requires integration with existing claims systems, which may involve IT coordination.
AI decisions may still need human validation in complex medical cases.
False positives, especially early in deployment, can require additional manual review.
No self-serve platform or free trial option available—enterprise consultation required.
Performance depends on quality of claims and documentation data provided.
Comparison with Other Tools
Alaffia Health operates in the claims review and payment integrity space, competing with legacy systems and other AI-first solutions such as Cotiviti, Optum Payment Integrity, and ClarisHealth.
Compared to Cotiviti and Optum, which offer broad analytics services and traditional recovery auditing, Alaffia stands out for its modern, AI-first architecture and focus on real-time claim validation.
ClarisHealth provides similar audit tools with rules engines, but Alaffia incorporates deeper clinical analysis using NLP, which makes it especially effective for claims supported by unstructured documentation.
Alaffia also differentiates itself by being nimbler and more flexible, making it easier for newer health plans and TPAs to adopt and integrate without overhauling existing systems.
Customer Reviews and Testimonials
Alaffia Health works with a growing number of payers and third-party administrators who have adopted the platform to modernize their claims operations. While individual testimonials are not publicly listed, Alaffia highlights successful engagements through white papers and customer briefings.
One payer case study reports double-digit improvements in overpayment recovery and a significant reduction in audit cycle times. Another client noted that Alaffia’s clinical insights led to improved provider education and better coding compliance.
Organizations are encouraged to request client references or results data during the discovery process with the Alaffia team.
Conclusion
Alaffia Health is transforming medical claims review through the power of AI, offering payers a faster, smarter, and more accurate way to validate claims and protect financial integrity. By replacing manual audits with real-time, scalable analysis, Alaffia helps health plans and TPAs detect overpayments, ensure medical necessity, and drive operational efficiency.
With its strong focus on explainability, integration, and clinical accuracy, Alaffia Health is an ideal solution for organizations looking to modernize their payment integrity workflows and improve the accuracy of every healthcare dollar spent.
