Secured Savings with Full Claim Review

With payment errors or overpayments expected to cost up to $560 billion, or 7-10% of healthcare spending in 2026, payers need solutions that maximize appropriate savings on every claim. By leveraging data across the life of a claim – and the patient journey – Vālenz^® Health has become the health plan’s partner of choice, offering Full Claim Review as part of our robust, end-to-end suite of Payment Integrity solutions.

Full Claim Review validates that care was medically necessary, provided by credentialed providers, and aligned with contracted requirements before applying our detailed claim review. Supported by AI and our expert coding and clinical review teams, we complement the health plan’s payment integrity capabilities with unique and proprietary methodologies, delivering savings that continuously exceed expectations.

Full Claim Review Services

Line item bill review

Clinical review by a nurse or physician

Improper, upcoding and unbundling review

DRG coding and clinical validation review

QPA review and analysis

Usual and customary charge review

Fraud, waste and abuse review

Comprehensive pre-payment review

Post-payment review and overpayment recovery through our Post-Payment Recovery solution

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Provider Negotiation and Signoff for Significant Savings

Our Full Claim Review spans in-network and out-of-network claims to ensure appropriate, accurate charges and defensible payments. We identify and correct unnecessary, unrelated or questionable medical billing, even after payment is made. Leveraging provider negotiation and signed agreements, our solution averages an additional 30% savings over contracted network discounts. In addition, our customers experience signoff success rates averaging 70%, with less than 1% of reviews overturned by providers.

Cost-Containment Strategies for High-Dollar Claims

With VMS^® Market-Sensitive Repricing, operational cost intelligence, and a foundation of expertly curated data sets and advanced analytics, Valenz unlocks additional savings for very high-dollar, usually low-utilization claims, including:

69%

average savings

Ambulatory Surgery Centers

50 - 80%

average savings

Air Ambulance

49%

average savings

Substance Abuse Treatment

25%

average savings

Renal Dialysis

25%

average savings

Specialty Medications

Reduce Costs and Secure Long-Term Savings with Full Claim Review

We consistently uncover additional areas of savings by delivering transparency through collaboration.

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Experience the Platform to Simplify Healthcare

With comprehensive pre-payment reviews and Post-Payment Recovery that ensure appropriate billing and accurate payments, Full Claim Review is part of the Valenz platform of fully integrated solutions that optimize cost, quality and utilization of care. Transform your payment integrity capabilities and simplify the complexity of self-insurance with Valenz as we drive smarter, better, faster and more cost-effective care for everyone.

Case Studies

Multi-State Health Plan

By uncovering errors and overpayments across high-dollar, in-network claims, we drove an additional $120 million savings beyond network savings – an average savings per claim of $40,000.

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Children’s Hospital

We found opportunities for nearly 14% in additional savings beyond the PPO discount and secured provider signoff, delivering our client $129,648 in net savings.

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High-Dollar Claims

Our line-by-line bill review for a catastrophic claim delivered $93,798 in net savings above the PPO discount, with 5% lower fees than the TPA vendor and no balance billing to the patient.

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