2024 Partners

AMS Intelligent Analytics

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

4L Data Intelligence

Website: https://4ldata.com/

4L Data Intelligence™ uses the patented power of Integr8 AI™ to find, fight and prevent fraud, waste, and abuse fast with the revolutionary provider-centric FWA approach. Integr8 AI technology, coupled with our continuously credentialed provider database, detects FWA you can’t see with claim data-centric approaches, solving a challenge every payment integrity platform has today.

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, Integr8 AI dynamically and continuously detects provider behaviors, relationships, and outlier status 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 delivered in four distinct categories. These are:

• Provider Integrity Edits
• Adaptive Claims Edits
• Provider Behavior Analysis
• Provider Schemes Analysis.

For fraud and SIU teams, Integr8 AI detects fraud and collusion schemes you can’t see now, or can’t see fast enough, with claim-centric approaches. Our suite of tools automates continuous near real-time SIU-in-a-box detection and documentation so you can Find, Fight and Prevent Fraud 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, and abuse 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. FWAShield™ offers the combination of targeted rules, artificial intelligence, shared analytics across multiple payers resulting in higher ROI (up to 20:1) compared to other vendors.  FWAShield™ software platform was developed by industry leading healthcare subject matter experts and is a component of over 50+ clients’ including 16 Blue plans Payment Integrity/SIU departments.  Our client satisfaction rating is exceptional with a net promoter score of 97 and client retention rate over 95%. 

FWAShield™ – is a fully integrated platform consisting of PreShield™ (pre-payment), AIShield™ (AI), PostShield™ (post-payment), RxShield™ (pharmacy analytics), Shared Analytics™, QueryShield™ (ad hoc query and reporting tool) and CaseShield™ (case management).

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/

Power & Modernization for the Healthcare Payment Continuum. Alivia’s revolutionary, AI-enabled Analytics Platform offers payer modules that include Claims Editing integrated with pre- and post-pay adjudication workflows to stop erroneous billing; FWA Finder™ that generates 100x more fraud and improper payment leads and unique FWA scenarios; Alivia Case Manager that opens 10x more fraud cases and decrease pre-case cost by 50-90% in our platform, or yours; VBC Insights for 1000+ Episodes of Care that shortens negotiation durations and lowers costs; and MCO Insights to support the encounter management submission process for Managed Care Organizations. We also address Payment Integrity challenges through Tech-Enabled Services performing FWA Investigations, Clinical Reviews, Recovery Audits, and ESRD Premium Protection. Alivia’s 2024 acquisition of SourcEdge added unique expertise to optimize core systems with Data Consolidation, De-Indentification, and Claims Systems IT. Our customers are commercial health plans to Medicare Advantage and Medicaid Managed Care Plans. Alivia delivers actionable insights, visible ROI, speed, and accuracy leveraging technology, medical, clinical, and law enforcement experience. HITRUST Certified.

https://www.aliviaanalytics.com/

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

DRG Claims Management

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

DRG Claims Management is an accuracy and integrity solutions firm, auditing claims for DRG and Clinical Validation, Cost Outliers, Readmissions, Short-Stay/OBS, and Skilled Nursing Facilities. Health Care Organizations partner with us to increase payment integrity savings and to improve claim payment performance. Our audits are completed on a Prepay, Post-payment or Hybrid basis.

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 automates the healthcare claims lifecycle from prior authorization through final payment utilizing AI-powered software. At the core of Machinify is an AI cloud platform that digests and unifies policies, guidelines, and data transforming healthcare administration. 

Machinify's platform powers three revolutionary applications that interoperate for seamless execution across the healthcare claims lifecycle:

• Machinify Auth: Comprehensive system automating the submission and processing of ALL service authorization requests.
• Machinify Audit: End-to-end system utilizing GenAI and large language models (LLMs) to perform automated coding validation of complex claims.
• Machinify Pay: Software that enforces coding and payment policies against claims and prices claims accurately.

Penstock Group

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

Penstock is a service partner and SaaS builder for forward-thinking health plans and providers, empowering recovery, audit and regulatory teams to get accuracy right from the start—when it matters most. 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.

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.