2024 Partners

AMS Intelligent Analytics

Website: http://www.amspredict.com/

 Advanced Medical Strategies (AMS) is the premier provider of payment integrity, risk management, and business intelligence solutions to identify and address excessive claims, prevent and recoup overpayments, and effectively manage the risks associated with high-cost claimants and group health underwriting.

4L Data Intelligence

Website: https://4ldata.com/

4L Data Intelligence™ is leading the way in a new era of healthcare program and payment integrity using the patented power of Integr8 AI Risk Detection™ technology to find, fight and prevent FWA in near real-time. Integr8 AI™, coupled with our continuously credentialed provider database, creates a revolutionary provider-centric capability to dynamically detect FWA you cannot see with stacks of traditional claims data-centric editing and analytics solutions.

The 4L FWA Prevention™ solution rapidly detects and prevents FWA at five points across the claims management workflow including pre pre-payment, pre-payment and post-payment positions. At each point, patented Integr8 AI technology dynamically and continuously detects provider behaviors, relationships and outliers without the limitations of rules-based and claim data-centric solutions. In short, it enables you to see what providers are doing individually, in relationship with all other providers, and in relationship to all other claims on each-and-every claim submitted.

4L FWA Prevention pre-payment and post-payment detection and prevention results are continuously delivered in four complementary modules. These are:

• Provider Integrity Edits
• Adaptive Claims Edits
• Billing Behaviors Analysis
• Provider Schemes Analysis.

For SIU teams, the new 4L SIU Hub™ packages the expanded range of Integr8 AI powered FWA detection behaviors and schemes into easy to use views with comprehensive investigation and lead management tools. This new capability increases FWA detection, reduces complexity and increases speed-to-decision on lead triage and investigation. All so you can Find, Fight and Prevent FWA Fast™.

Ceris Health

Website: https://www.ceris.com/

CERIS has 30 years of prepay and post pay claim review and repricing experience with a 97% client retention rate. Our solutions are deep, consistent, and defensible reviews, which make CERIS the partner of choice for health plans, Medicare and Medicaid plans, and third-party administrators. CERIS’ longstanding review services and clinical expertise offer incremental value and are grounded in a sincere dedication to our valued partners. CERIS' mission is to continue to grow and deliver long term Payment Integrity services for our partners and to help them save.

CGI

Website: https://www.cgi.com/us/en-us

Founded in 1976, CGI is among the largest IT and business consulting services firms in the world. We are insights-driven and outcomes-based to help accelerate returns on your investments. Across hundreds of locations worldwide, we provide comprehensive, scalable and sustainable IT and business consulting services that are informed globally and delivered locally.

Healthcare Fraud Shield

Website: https://www.hcfraudshield.com/

Healthcare Fraud Shield specializes in fraud, waste, abuse, & error detection and payment integrity for healthcare payers nationally by efficiently stopping claims prior to payment using utilizing post-payment advanced analytics and artificial intelligence insights. We save health plans millions annually incremental to existing pre-payment processes using our unique and proven approach. HCFSPlatform™ offers the combination of targeted rules, artificial intelligence, and shared analytics across multiple payers resulting in higher ROI (up to 20:1) compared to other vendors. HCFSPlatform™ software platform was developed by industry leading healthcare subject matter experts and is a component of over 60+ clients including 7 of the 10 largest commercial insurers in the US. Our client satisfaction rating is exceptional with a net promoter score of 94 and
client retention rate over 95%.

HCFSPlatform™ is a fully integrated platform consisting of PreShield (prepayment analytics & claim review logic), PostShield (post-payment analytics), AIShield (AI-driven analytic insights), RxShield (pharmacy and pharmaceutical specific analytics), Shared Analytics, CaseShield (SIU/PI case management), QueryShield (ad hoc query and reporting tool), HCFSServices (data mining, investigative, and record reviews), and HCFSAudit (Medical Record Review & SVRS). 

MedReview

Website: https://www.medreview.us/

Headquartered in the financial district of New York City and serving all U.S. states and territories, MedReview has been a leading provider of payment integrity, utilization management and quality surveillance services for more than 40 years. A physician-led organization with a passion for ensuring that health care claims fairly represent the care provided, MedReview provides timely independent hospital billing audits and clinical validation reviews on behalf of health plans, government agencies and Taft-Hartley organizations, saving millions of dollars for its clients each year.

6 Degrees Health

Website: https://www.6degreeshealth.com/

6 Degrees Health is on a mission to reduce the cost of healthcare. We take a service-first approach to our Clean Claim Reviews to ensure accuracy in billing and fair payments. Using our extensive cost containment experience, clinical expertise, and next-generation, purpose-built software, we deliver remarkable savings for health plans. Our proprietary review process leverages CMS and other industry standard guidelines to evaluate every line item and identify billing errors and inconsistencies.

These pre-pay clinical reviews are completed by our team of highly trained and experienced registered nurses to ensure each billed line item is appropriate for reimbursement. This detailed review removes erroneous line items and verifies billing accuracy. Our comprehensive process manages claims during the review stage, as well as through payment and appeals resolution. Our white glove service on appeals allows us to maintain an uphold rate of 97 %, so your savings are secure.

Alivia Analytics

Website: https://www.aliviaanalytics.com/

Your most expansive Payment Integrity and FWA partner for medical, pharmacy, vision, and dental claims. This features our powerful, configurable Alivia 360™ Platform that provides pre- and post-payment flexibility and considerable cost savings across the healthcare claims management process. It seamlessly transitions between FWA detection and Payment Integrity solutions including clinical and non-clinical audit scenarios, first- and second-pass claims editing, and COB/TPL. Alivia 360™ not only ensures comprehensive financial oversight but full adaptability to operational needs. Alivia integrates AI as an assistant, not a replacement, prioritizing ethical use, human oversight, and compliance with industry standards. Our solutions are offered as SaaS or tech-enabled services that build strong cases against inappropriate billing practices, identify new recoveries missed by legacy vendors, deliver actionable analytics, and offer automated corrections. Alivia enables healthcare payers to streamline vendor management, improving control and strategic decision-making. Schedule a discovery meeting and demo.

Apixio

Website: https://www.apixio.com/

Apixio, formerly ClaimLogiq, is the Connected Care Platform at the intersection of health plans and providers. Our AI technology and flexible services power risk adjustment, payment integrity, and care delivery programs using centralized patient health profiles, data-driven insights, and seamless workflows. By combining ClaimLogiq and the Apixio technology ecosystem, healthcare organizations can streamline operations, ensure accurate payment, and uncover critical patient insights—building a resilient foundation for success as the industry moves toward value-based reimbursement models. Visit apixio.com to learn more.

CoventBridge

Website: https://coventbridge.com/

CoventBridge Group has more than 25 years of experience in the identification, prevention and investigation of fraud, waste, and abuse for our customers across the healthcare, insurance, financial and government markets with a proven track record of implementing and managing the largest programs in the industry. CoventBridge is the partner of choice supporting:

-          8 of the top 10 commercial carriers in the U.S.

-          7 of the top 10 personal line carriers in the U.S.

-          Centers for Medicare and Medicaid Services as the Program Integrity contractor investigating Healthcare FWA

-          One of the largest government agencies providing a national network of undercover investigators

CoventBridge offers the following services and more via its 500+ investigators:

Program Management

• Audits & Assessments

• Compliance Assessment

• Medicare & Medicaid FWA

• On-site Audits

• Vendor Management

Document Retrieval & Analysis

• Medical Record Retrieval

• Medical Record Review & Coding (RN)

• Investigative Medical Record Review

• Medical & Healthcare Canvassing

Investigative Services

• Healthcare FWA Investigations

• Investigative Reports

• Clinical Surveillance

• Law Enforcement Referrals

• Alive and Well Checks

Staff Augmentation

• Data Analysts

• Investigators

• Nurse Reviewers

• RN Consultants

Data In Formation

Website: https://liberty-source.com/

Liberty Source PBC is a U.S.-based provider of technology-enabled human-in-the-loop data services that help companies realize maximum value from their Artificial Intelligence, Machine Learning, and Business Intelligence investments. Through its flagship DataInFormation brand, the company provides image annotation, data labeling, computer vision calibration, NLP validation, training data curation, prompt engineering, model monitoring / data lineage evaluations, and related data optimization services.

100% of facilities, operations and workforce are US-based to provide the highest level of information security; to minimize time zone issues; and to eliminate challenges arising from different cultural interpretations of data. 80+% of the staff are veterans or members of military families.

Liberty Source has deep domain expertise in a wide range of industry verticals. Extensive capabilities and a nimble culture are key differentiators that enable the company to fulfil even the most rigorous client requirements.

DRG Claims Management

Website: https://www.drgclaims.com/

DRG Claims Management (DCM) is an accuracy and integrity solutions firm, auditing claims for DRG (APR/MS) Pricing, Coding, and Clinical Validation, Cost Outliers & Itemized Bill Reviews, Readmissions, Short-Stay/OBS, Surgical Implants, Wound Care, and Skilled Nursing Facilities (PDPM/RUGs). Health Care Organizations partner with DCM to increase payment integrity savings and improve claim payment performance.

Our audits are completed on a Pre-pay, Post-pay, or Hybrid basis and encompass Tricare, Medicare, Medicaid, and Commercial payers.

HealthPlan Data Solutions, Inc.

Website: https://hds-rx.com/

Bridging the divide between payers and PBMs with payment integrity solutions. HDS is a software solutions company that leverages leading-edge technology paired with pharmacy expertise to help payers proactively manage the performance of their PBM. Our PBM-agnostic approach leverages over 500 proprietary claim scanning algorithms that are custom coded to identify, monitor, and fix claims adjudication issues ranging from plan design implementation errors to compliance and regulatory errors. Our unique approach to payment integrity is more than PBM auditing and places all the information at the payers fingertips. Your pharmacy data. One platform. Complete visibility.

Machinify

Website: https://www.machinify.com/

Machinify is the trusted AI partner for healthcare admin, providing software and services that enable health plans to accurately and efficiently pay claims, leading to a reduction in provider abrasion. With safe, transparent AI and deep clinical expertise, Machinify brings a unique blend of speed, accuracy, and intelligence health plans need to make healthcare admin more efficient.

The company serves partners of all sizes with its two products:
● Machinify Audit - Medical AI system identifying erroneous claims and performing record review.
● Machinify Pay - AI models and SME expertise to process claims at wire speed, ensuring accurate coding and pricing.

Penstock

Website: https://www.penstockgroup.com/

Penstock is a service partner and SaaS builder for forward-thinking health plans, arming recovery, audit and regulatory teams with the tools and insights to enhance payment and regulatory accuracy. Our mission is to create lasting systemic change that removes wasted spend from our healthcare system, returning dollars to payers, lowering the cost of care and improving access for all.

Penstock is powered by industry veterans who are some of the most sought-after payment integrity and regulatory experts in the industry. Our business model is rooted in transparency and the drive to reinstate true integrity in payment integrity—even if it defies traditional business sense.

Our audit workflow SaaS platform, ClearBridge gives health plans the tools and insights they need to identify overpayments, correct them and implement their own edits with ease, ensuring correct payments and mitigating future discrepancies.

When you partner with Penstock, you reclaim time and control with an end-to-end partnership that beautifully and seamlessly connects human and machine intelligence—to prevent recurring issues at the source.

When you partner with Penstock, you reclaim time and control with an end-to-end partnership that beautifully and seamlessly connects human and machine intelligence—to prevent recurring issues at the source.

Trend Health Partners

Website: https://www.trendhealthpartners.com/

Combining the strengths of Trend, PrecisionGX and Advent, Trend Health Partners emerges as a pioneer in healthcare financial optimization, delivering unparalleled  payment integrity and revenue cycle expertise since 2010. As a trusted partner for providers and payers, we are dedicated to elevating payment accuracy and reducing administrative costs through our innovative, tech-enabled solutions. Our robust platform and clinical team operate as a seamless extensions of a provider’s business office, resolving credit balances, overturning denials and managing claims with precision and efficiency.

At Trend Health Partners, we personalize our approach to meet the unique needs of each client, ensuring the recovery and saving of billions of dollars while supporting their long-term financial objectives. We are committed to accelerating accurate reimbursements and enhancing revenue integrity by merging clinical insights, best practices, and cutting-edge technology.

Our mission extends beyond financials; we foster collaboration and transparent communication across the healthcare spectrum, offering a suite of services that drive significant value for all stakeholders. With a legacy of industry leadership, Trend Health Partners stands at the forefront of healthcare innovation. Together, we are setting new benchmarks for collaboration, transparency and integrity in the healthcare industry.