#1 AI Claims Auditing Solution for Payers

Virtual Reporter® allows your team to isolate high-impact claims instantly using customizable filters based on dollars, providers, CPT/HCPCS codes, or specific edit types. Instead of reviewing everything, teams can focus on the highest-risk and highest-value claims first—reducing review time while increasing financial impact.

Every organization operates differently. VR can be configured to match your internal workflows, reporting needs, and decision thresholds—whether by line of business, provider group, or claim type. This ensures your team is reviewing claims in a structured, consistent format aligned with your operational and compliance goals.

Virtual Reporter® includes a contract module where your team builds and maintains DOFR structures, provider contracts, and fee schedules. Once configured, VE applies these terms during claim review so reimbursement is evaluated against how you are contractually obligated to pay—not just standard coding rules. This ensures contract-specific overpayments and inconsistencies are identified in line with your actual agreements.

Within Virtual Reporter®, your team can define exclusions by provider, billing group, billing ID, or specific lines of business. This allows you to remove known scenarios from review, reduce unnecessary noise, and focus audit efforts only on claims that require action—keeping workflows clean, targeted, and efficient.

Quickly surface providers with abnormal billing behavior, such as a single physician billing modifier -25 on 70%+ of E&M visits, or a facility repeatedly submitting high-level E&M (99215) at rates far above peers. VE also flags providers with frequent duplicate billing patterns or consistent use of mutually exclusive procedures, allowing your team to isolate risk immediately.

Evaluate providers against similar specialties and regions to identify true outliers. For example, a cardiologist billing stress tests 2–3x more frequently than comparable providers, or a surgical group consistently applying modifier -59 at significantly higher rates than peers. This removes guesswork and ensures investigations are based on measurable variance, not assumptions.

Monitor how provider behavior changes across months and years. For example, VE can identify a provider who suddenly increases use of modifier -25 or -59 after a contract update, or a group whose average reimbursement per claim steadily rises due to coding shifts. These trend insights allow early intervention before issues scale into material financial or compliance exposure.

Provide structured data to support investigations and corrective action. For example, VE outputs can be used to document repeated unbundling patterns, support provider education on modifier misuse, or escalate cases where billing behavior suggests potential fraud, waste, or abuse. This ensures your SIU and compliance teams act with defensible, data-backed evidence.

Identify issues upfront, such as modifier -25 applied without a separate E&M, -59 used where NCCI bundling applies, or invalid code combinations that would later deny. Teams can correct claims before they enter the payment cycle.

Run mock adjudications to see how a claim will process under your rules. For example, test professional vs technical splits (-26/-TC), evaluate multiple procedure reductions, or confirm fee schedule reimbursement based on contract terms before finalizing decisions.

Evaluate requests during the authorization process, such as confirming whether a procedure requires prior auth under CMS guidelines, or identifying when a request should be approved, reduced, or flagged for review based on coding and utilization logic.

Ensure claims, authorization, and contracting teams are aligned. Instead of relying on varying interpretations, everyone uses the same validated logic to assess scenarios like frequency limits, diagnosis requirements, or bundled services, reducing errors and internal discrepancies.