ClaimShark Platform

ClaimShark Platform

Payment Integrity
Orchestration and Insights Platform

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THE PROBLEM

Payment Integrity teams are under pressure to find more savings while reducing administrative costs and provider abrasion. But aging technology and manual processes create inventory blind-spots, delay accruals, and generate abrasion. As a result, payers are stuck in a vicious cycle, missing key insights, and leaving millions on the table

GO DEEPER

Vendor and Audit Orchestration Yield Management and Conversion Rates Concept and Rules Management Provider Relations and Disputes Data and Reporting

Vendor and Audit Orchestration

Payers and Vendors are burdened by the integrations and file exchanges required to perform audits.
This forces payers to compromise, and limit their PI Audits due to IT costs and implementation complexities
Further, the manual file and vendor orchestration increases administrative costs and must be maintained and updated regularly, taking IT teams away from other important projects

Yield Management and Conversion Rates

Legacy systems and manual processes leave tens of millions in savings untapped, as payers struggle to act on audit findings.
Manual claim validation eats up time and cash, resulting in expired claims, ballooning costs, and shrinking ROI.
Months are lost converting overpayments into savings—avoidable delays caused by manual reviews, outdated systems, and waste.

Concept and Rules Management

Payers aren’t clear on which audits drive savings and which create waste, causing inefficiencies and abrasion.
Lengthy pros-and-cons evaluations hold up audit concepts that could be fast-tracked with better data access.
Flexibility and precision are key—yet health plans are shackled by rigid, one-size-fits-all systems that limit potential savings.

Provider Relations and Disputes

Without a comprehensive platform and the right data, subjective decisions dominate, causing missed opportunities and concept shutdowns.
Limited tech forces payers to push the burden of defending recoveries onto providers, driving up frustration and friction.
Manually applying tens of thousands of complex rules leads to errors, avoidable provider abrasion, and compliance headaches.

Data and Reporting

Payment Integrity leaders need access to insights but are blind to the full picture, with vital data trapped in disconnected systems.
Providers are stepping up their game, outpacing payers with a deeper understanding of audit performance, leading to lost leverage.
Vendor performance data is scarce, making it hard for health plans to optimize vendor stacks, leaving savings and quality on the table.

OUR SOLUTION

ClaimShark is a comprehensive, AI-Powered platform that streamlines the entire payment integrity operation. Comprehensive inventory management empowers teams with insights and reporting. Automated workflows and a flexible rules engine accelerate accruals, reduce abrasion, and improve administrative efficiency.

ClaimShark simplifies payment integrity operations across both pre- and post-pay, so payers can maximize savings, minimize costs, and improve provider relationships.

Orchestration of Vendors & Files

problem

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Understand every
Payment integrity audit
At every level

Vendor, Audit, & Concept Performance Insights
Provider Impacts and Longitudinal Billing Behavior
120+ Reports, KPIs & Ad-Hoc Reporting
Eliminate Leakage with Fine Tune Control

OUR PLATFORM

Key Features

RAPID IMPLEMENTATION
Accelerate speed to value
RULES, EDITS & WORKFLOWS
Full control for compliance and efficiency
FLEXIBLE FILE FORMATS
We will meet you where you are
COMPREHENSIVE DOCUMENT REPOSITORY
Charts, letters, contracts, etc.
REDUCE APPEALS
Lower abrasion from controlled workflows
COMMUNICATION MANAGEMENT
Letters, Portal APIs, and more

BENEFITS

Access Key Insights for Cost Avoidance
Reduce Provider Appeals
Reduce Costs
Improve Quality
Ensure Compliance
Access Data