For payers & health plans
Deny defensibly.
You don't spend integrity dollars to win a fight. You spend them to be right. We surface findings that hold up on rebuttal — with the clinical and contractual evidence already attached.
The problem with one-sided integrity
Vendors that promise 100% of flagged exposure is recoverable are the ones whose findings collapse the moment a provider rebuts. Cost-to-pursue climbs. Provider abrasion climbs. Net recovery falls.
"Showing you the gray zones isn't a weakness. It's how we make sure every dollar you pursue is defensible."
Act 01 — The objection
"We don’t need more flags. We need more staff."
01 The staffing answer
You’re right.
Flags don’t file themselves.
Every SIU says it, every year — and every analytics vendor answers with another dashboard. We answer with finished work: every flag arrives as a signed determination package — evidence, citations, counter-case, recommendation — awaiting one thing: your signature.
Imagine the best attorney you know. Give them every contract, every statute, every regulation — and have them review every claim, in real time, for your whole team. We built the attorney. You keep the signature.
stage 01
Detection
55 learned pattern types find it — signatures, not written rules.
stage 02
Investigation
5-lens analysis builds the case — billing, clinical, systemic, statistical, historical.
gate 1 · the seal
Nothing uncited ships
Self-review gate: every citation current, hash-signed. ~14% of our own work blocked※self-review gate · engineering telemetry before a human ever sees it.
stage 03
Adjudication
Advocate · Defender · Arbiter argue it — both briefs on every claim.
gate 2 · the signature
A person decides
Every determination signed by a human. Never deny through automation — ever.
stage 04
Resolution
Graduated response: educate · recover · refer. Proportional, defensible.
And the part your network team will love: the same package is visible to payer, provider, and reviewer. The provider sees the evidence before the recoupment letter — which is why this process has driven provider engagement up, not abrasion.
the part everyone asks about
The RFI is where
most programs drown.
Anyone can request records. It’s the 100,000 pages that come back — faxes, scans, PDFs, portal exports, in every format providers can produce — where staffing dies and provider relationships sour.
We don’t flag and walk away. We engage: the ask is precise — driven by your data, this payer’s patterns, this jurisdiction’s rules — and when the records return, the model reads them, mapping unstructured clinical text onto the care and claims strands until there’s a single picture of the patient’s journey.
Precise ask
Only what decides the claim — provider burden goes down, not up.
Pages return — every format
No analyst reads them. The model does — mapped to care · claims, cited to the chart.
Patient journey
One coherent picture — the clinical strand your determination was waiting for.
one precise ask · 100,000 pages back · one patient journey out — burden down on both sides of the seam
Act 02 — The read
Trajectories, both directions — not line-item flags.
02 What changes
Trajectories, not single claims. Both directions, not just yours.
Treatment trajectory
Episodes, not line items
We analyze the clinical trajectory across the whole episode of care — the way over-utilization actually shows up — instead of flagging individual claims a rules engine can't defend. Supports compliance and appropriate care.
Confidence-tiered
Know what's recoupable
Every finding is tiered by confidence — near-certain rule violations vs. clinical-judgment calls — with the published false-positive range and the regulation it rests on. You decide where to spend effort.
Objective broker
Underpayments too
We surface overpayments and underpayments. Roughly a third of what we find runs the other way — a credibility asset when you sit across the table from a provider.
Act 03 — The proof
Tens of millions of claim lines, already read.
03 Proven on payer books at scale
Tens of millions of claim lines. The patterns rules never caught.
Working with a top-5 U.S. integrated payer covering nine million members, the engine analyzed more than 50 million claim lines across four years and discovered 28 novel detection patterns — behavioral health, ABA, PT, ER, home health — that traditional edits don't see.
See a glass-box determinationAct 04 — The voice
What payer leadership actually wants.
04 The payer line
"I want to set the contract, monitor it, and let my members get the best access at the best quality — instead of spending hundreds of millions gaming with my providers."— a Blue Cross Blue Shield CEO, in conversation
Act 05 — The terms
How we engage — risk shared.
05 The terms
We get paid
when you do.
No seats. No shelfware. No report that dies in a drawer. Results as a service — the agents do the work, your people approve it, and the risk is shared.
01 · two weeks · fixed
The Read
Your book, sequenced — exposure and underpayments by confidence tier, every number with SQL provenance.
02 · per-claim
Prevent
The 19µs pre-payment harness on your adjudication flow — priced on prevented loss, earned autonomy.
03 · both directions
Recover
Findings that survive rebuttal — and the third that runs the other way, surfaced too. Credibility is the asset.
fewer false positives · lower abrasion · every dollar defensible
From readout to recovery
A portfolio assessment on your own claims.
We run your book, return claim-level evidence packages with SQL provenance for every number, and stand up the first recovery sprints — in weeks, not quarters.