Providers

Improve quality and reduce the total cost of care with our interoperable Care Management platform — built on a foundation of automation, standardization and mature processes and using data from renowned, industry-standard COTS products like the Johns Hopkins ACG® System as well as administrative and clinical information.

Identify coding, location, level of service and reimbursement errors pre- or post-pay. Our Clinical Claim Reviews solution uses artificial intelligence to select the claims most likely to have errors and clinical expertise to compare them against medical records.

Simplify provider billing with comprehensive validation rules for managed care and fee-for-service transactions and ensure your encounter data is compliant through a single point of submission.

Verify member eligibility while providing clarity on the decision to staff — ensuring they can explain, with sensitivity, why someone is ineligible.

Gain end-to-end support in the identification of fraud, waste and abuse. Our modular, cloud-hosted platform exposes issues through clear visualization and easy-to-navigate exploration tools.

Pinpoint claims that have been improperly billed or paid while minimizing abrasion in the process. Our Payment Analytics solution uses proprietary data analysis tools to compare claims history across many criteria that client systems or claim processors often miss.

Capture and recover dollars lost as a result of improperly paid claims. Our Post-Payment solutions leverage AI and machine learning to ensure accuracy in the claims review process and efficient, digital processes to pursue recoveries and maximize savings.

Maximize cost avoidance for your plan or program. Our tenured market expertise pairs with our end-to-end COB solutions to amplify speed to delivery and provide truly actionable insights.

Automate and expedite authorizations for your state with configurable rules and workflows designed to improve member and provider satisfaction.

Create new efficiencies within provider management processes, from initial enrollment through final determination letters to support participation in fee-for-service and managed care programs.

Validate the appropriateness and necessity of services and procedures to contain costs in your plan or program. Utilization Management addresses your most pressing needs by combining cost management with accurate pre- and post-payment claim reviews and prior authorization from our Clinical Care Reviews.