Audit.ai | AI Healthcare
Payment Integrity Platform
Audit healthcare claims before payment using AI to identify coding errors, fraud risk, documentation gaps, and coverage conflicts.
The problem.
Recovery starts before
payment.
Pay and chase is the order of operations almost everywhere. The claim gets paid. The dollar leaves the plan. Recovery becomes a slow negotiation that clears cents on the dollar.
Audit.ai changes the order. Six audit layers run before adjudication. When fraud or overpayment shows up, the dollar does not.
How a claim gets audited.
Six layers per facility, adapting to specialty. Thirty stages. Twenty-nine audit functions. Each layer retools per line of business: vision, dental, medical, DME, pharmacy.
Intake and Eligibility
Standardizes and validates member data, coverage mapping, and historical linkage before the claim enters adjudication. This layer catches eligibility mismatches, duplicate member records, and coverage gaps before any downstream processing begins.
Every claim gets a verdict.
Six outcomes, clearly reasoned. No claim leaves without a verdict, its category, and the checks behind it.
Fully compliant, ready to pay. Proceed to adjudication and payment.
Violates policy or coverage. Deny with policy citation attached.
Intentional deceptive billing detected — phantom billing, identity fraud. SIU escalation triggered.
Excessive or improper utilization — duplicate component billing. Investigation queue.
Coding or documentation mismatch — revenue code error, modifier missing. Route to correction.
Awaiting manual review. Flagged for auditor queue with reasoning attached.
What one audit surfaces.
Figures shown represent a complete pre-payment health plan audit, not sampled.
Total Run Overview
Coverage across active healthcare facilities
ClearVision Audit
1,204 Claims full resolution status
Sum: Exactly 1,204 processed
Smart Filter
Pre-payment audit run · 9,716 claims total · Complete pipeline
| Claim ID | Patient | Specialty | Provider | CPT Code | Value (USD) | Verdict | Audit Findings |
|---|---|---|---|---|---|---|---|
| CLM-9832 | J. D. | Vision | Dr. Smith | 92014 | $1,250 | Passed | Routine billing, fully compliant. |
| CLM-7741 | A. M. | Surgery | Mercy Gen | 22551 | $14,400 | Coding | Modifier 59 missing on secondary. |
| CLM-5529 | R. K. | Dental | Valley Dental | D2740 | $1,100 | Fraud | Duplicate crown billing detected. |
| CLM-1184 | S. T. | Medical | City Clinic | 99215 | $350 | Hold | Level 5 visit without supporting documentation. |
| CLM-3920 | M. P. | Pharma | CareRx | J0178 | $4,800 | Denied | Prior authorization missing for specialty drug. |
| CLM-8842 | L. L. | OB/GYN | Women's Health | 59400 | $3,200 | Passed | Global maternity package verified. |
| CLM-2105 | E. C. | Medical | Dr. Jones | 93000 | $150 | Hold | Awaiting manual review for unbundling. |
| CLM-4417 | B. N. | DME | MedEquip Co | E0601 | $2,900 | Abuse | Excessive supply billing per member history. |
Wound.ai — Revenue Integrity for Wound Care Programs
Wound.ai applies Grelin's intelligence platform to the documentation, coding, and payer policy requirements unique to wound care — including WISer and complexity-based reimbursement.
- Match documentation to complexity-based reimbursement requirements
- Align coding with wound care-specific payer policies
- Navigate reimbursement complexity automatically
Chart Assessment
Upload a wound care chart and let AI analyze it.
Drop PDF, image, or TXT here to upload
PDF, TXT, PNG, JPG, JPEG, WEBP
Automated staging and complexity analysis based on real-time clinician input.
Real-time alerts for missing debridement and documentation gaps.
Every documentation action is timestamped, traceable, audit-linked.
Pain.ai — Revenue Integrity for Pain Management
Pain.ai applies Grelin's intelligence platform to the regulatory and coding requirements of pain management — validating CPT accuracy, modifier use, and payer policy alignment.
- Analyze documentation and coding patterns
- Align with payer policy requirements
- Prevent denials and maintain consistent performance
Real-time LCD/NCD compliance mapping before claims reach the clearinghouse.
Automated CPT/ICD crosswalks specific to interventional pain procedures.
Simulates payer audit logic to flag potential denials before submission.
Payer Integrity, Uncompromised.
"Audit.ai does not replace the auditor. It lets a one hundred percent audit ship verdicts faster, with the reasoning already attached, and more recovery dollars on the run for every payment integrity team that deploys it."
See Audit.ai on your own claims.
Bring a representative claim parameters below. Run it through our interactive six layers and generate a reasoned, defensible queue verdict instantly.
Support Center
Frequently Asked Questions About Audit.ai
Find answers about Audit.ai, pre-payment claim auditing, payer policy validation, medical necessity, and AI-powered claims auditing.
What is Audit.ai?
Audit.ai is Grelin's claim auditing application for payers. It reviews claims before payment, checks them against coding standards, medical necessity logic, documentation, and the payer's own policy set, and returns a verdict with the reasoning and policy basis behind it.
What is payment integrity?
Payment integrity is how payers confirm claims are paid correctly: to the right party, for covered services, at the contracted rate, with no error or fraud. Historically it relied on post-payment audits and recovery. AI moves the same checks before payment.
What is the difference between payment integrity and claim integrity?
Payment integrity is the payer's discipline of paying claims correctly, and it has mostly worked after payment. Claim Integrity applies the same validation on both sides of the transaction, before submission and before payment, so wrong claims are prevented rather than recovered.
What is the difference between a pre-bill audit and a post-pay audit?
A pre-bill audit reviews a claim before it is submitted, while the encounter can still be corrected. A post-pay audit reviews a claim after money has moved, and any error becomes a recovery effort. Pre-bill audits prevent the loss. Post-pay audits chase it.
What is payer policy validation?
Payer policy validation checks a claim against the specific payer's coverage rules, medical policies, prior authorization requirements, and coding edits before submission or payment. Because payer policies change frequently, validation must continuously stay up to date to ensure claims remain compliant.
How does AI detect healthcare fraud, waste, and abuse?
AI screens claims against coverage rules, coding standards, and historical billing patterns at full volume, flagging outliers that would be difficult for manual audit teams to review. It helps identify potential upcoding, unbundling, duplicate billing, impossible utilization, and other patterns of fraud, waste, and abuse before payment is released.
What is DRG validation?
DRG validation confirms that an inpatient claim's diagnosis-related group (DRG) is supported by the medical record. It verifies that the principal diagnosis, secondary diagnoses, and procedures are documented and coded correctly, helping prevent costly overpayments caused by inaccurate DRG assignment.
What is coding compliance?
Coding compliance means healthcare claims are coded according to official coding guidelines and payer policies. This includes selecting the correct ICD-10 and CPT codes, applying appropriate modifiers, and avoiding errors such as unbundling or upcoding. Strong coding compliance helps providers protect revenue while preventing improper payments for payers.
Still have questions?
We're here to help you navigate the complexities of revenue cycle intelligence.
Who it is for, and the close.
Built for the payer side of the wire. Payers and health plans. Audit organizations. SIU and payment integrity teams. Government program integrity.
Book a demo & analysis
See Audit.ai on your own claims. Bring a representative claim file. We will run it through the six layers and hand back a reasoned queue you can defend.