Pre-Pay

Lead Access & Prioritization: Eligibility data is spread across various sources, but system limitations make it hard for plans to leverage all leads, causing missed savings opportunities.

Verification: Verifying leads is slow and tedious, resulting in delays, expired claims, and lost savings.

Centralized Primacy Engine: Without a unified primacy logic engine, manual determinations drag out cycle times and spike error rates.

Post-Pay

Claims Analysis & Recovery: Many teams process claims ‘first in, first out,’ wasting time on low-value claims, driving down ROI.

Rules Management: Navigating state regulations and provider exclusions without a flexible platform leads to errors, compliance issues, and provider abrasion.

Adjustments & System Updates: Manual claim and eligibility adjustments across multiple teams result in delays, errors, and extra costs.

Quality and Compliance Audit Challenges

Claim Selection: Static selection criteria trap teams in repetitive findings, missing out on new and emerging issues.

Efficiency: Aging systems, disconnected tools, and manual processes constrain audit teams that are already at full capacity.

Root Cause Correction: Without a single platform to manage findings, rebuttals, and escalations, accountability is lost, leading to recurring issues and wasted resources.