TalentLNX Payment Integrity Readiness Scorecard

Answer all 10 questions to identify your payment integrity program's strongest capabilities and critical gaps in clinical talent, data science, and operational maturity.

1. DRG/Prepay Program Sophistication

Rules-based system only; no data science integration (0 pts)

Basic DRG audit program; manual exception handling (3 pts)

Automated DRG validation; statistical outlier detection (7 pts)

ML-driven prepay optimization; predictive DRG grouping with validation (10 pts)

2. AI/ML Claims Selection & Prediction Capability

Manual claim selection; no algorithm-driven prioritization (0 pts)

Basic rule-based selection; ad-hoc predictive logic (3 pts)

Established predictive models; claims scored by risk/savings potential (7 pts)

Advanced ML ensemble; dynamic claim prioritization, real-time model updates (10 pts)

3. Clinical Review Bench Strength (RN/MD/Coding Expertise)

Limited clinical reviewers; external contract dependency (0 pts)

3-5 RN/MD reviewers; basic coding auditor team (3 pts)

8-12 RN/MD reviewers; established coding audit center (7 pts)

15+ clinical reviewers + CDI team; specialty expertise (cardiac, oncology, orthopedic) (10 pts)

4. Data Science Depth & Healthcare Analytics Capability

No data science team; vendor-dependent (0 pts)

One analyst; basic reporting and trend analysis (3 pts)

3-4 data scientists; established predictive models, claims NLP capability (7 pts)

6+ data scientists; clinical NLP, fraud detection models, model governance (10 pts)

5. SIU Leadership & Fraud Network Capability

No dedicated SIU function (0 pts)

One SIU coordinator; basic case investigation (3 pts)

SIU director + 2-3 investigators; pattern detection, network analytics (7 pts)

SIU COE; specialized healthcare fraud expertise, provider red-flag system (10 pts)

6. Vendor & Third-Party Auditor Mix Diversification

Single vendor; high dependency (0 pts)

Two vendors; one dominant (>80% volume) (3 pts)

2-3 vendors; balanced load, active diversification (7 pts)

3+ vendors + in-house COE; insulated from single-vendor risk (10 pts)

7. Audit Defense & Provider Abrasion Management

Minimal appeal process; high provider dissatisfaction (0 pts)

Basic appeals; limited documentation or escalation (3 pts)

Formal appeals process; clinical review escalation, provider relations team (7 pts)

Tiered appeal process; peer-to-peer review, proactive provider education (10 pts)

8. Savings Reporting & Economic Impact Visibility

No formal savings reporting; estimates only (0 pts)

Annual savings report; limited by use case (3 pts)

Quarterly savings dashboard; DRG, denial, and audit savings tracked (7 pts)

Real-time ROI analytics; savings attribution by program, predictive ROI modeling (10 pts)

9. Analytics Infrastructure & Technology Stack Maturity

Spreadsheet-based operations; no unified data platform (0 pts)

Basic BI tool; siloed dashboards, limited interoperability (3 pts)

Unified data warehouse; integrated analytics, automated reporting (7 pts)

Enterprise data lake + ML platform; real-time data, self-service analytics (10 pts)

10. Domestic vs. Nearshore (LATAM) Operational Footprint

100% domestic; no nearshore strategy (0 pts)

Early nearshore pilot; <20% of volume, limited oversight (3 pts)

Established nearshore; 20-40% volume, coding audit center build (7 pts)

Mature hybrid model; 40%+ nearshore, in-country leadership, quality parity (10 pts)

Payment Integrity Readiness Score

Payment Integrity Readiness Scorecard

Readiness Assessment

1. DRG/Prepay Program Sophistication

2. AI/ML Claims Selection & Prediction Capability

3. Clinical Review Bench Strength (RN/MD/Coding Expertise)

4. Data Science Depth & Healthcare Analytics Capability

5. SIU Leadership & Fraud Network Capability

6. Vendor & Third-Party Auditor Mix Diversification

7. Audit Defense & Provider Abrasion Management

8. Savings Reporting & Economic Impact Visibility

9. Analytics Infrastructure & Technology Stack Maturity

10. Domestic vs. Nearshore (LATAM) Operational Footprint

Your Top 3 Priority Actions

Unlock the Scorecard

Payment Integrity Readiness Scorecard

Readiness Assessment

1. DRG/Prepay Program Sophistication

2. AI/ML Claims Selection & Prediction Capability

3. Clinical Review Bench Strength (RN/MD/Coding Expertise)

4. Data Science Depth & Healthcare Analytics Capability

5. SIU Leadership & Fraud Network Capability

6. Vendor & Third-Party Auditor Mix Diversification

7. Audit Defense & Provider Abrasion Management

8. Savings Reporting & Economic Impact Visibility

9. Analytics Infrastructure & Technology Stack Maturity

10. Domestic vs. Nearshore (LATAM) Operational Footprint

Your Top 3 Priority Actions