Payer solutions

Insights-driven, transformative
healthtech consulting.

Healthtech solutions

Payer
solutions

Digital health
solutions

DELIVERING BUSINESS CONFIGURABLE SOLUTIONS

Our team of seasoned consultants is dedicated to guiding national and regional health plans through complex challenges, facilitating the implementation of straightforward and effective solutions.



Our consultants prioritize collaboration and innovative thinking, working alongside you as a cohesive team. We bridge the gap between business and IT with proven industry expertise, delivering scalable, business-driven technology and process solutions. Our approach harnesses emerging technologies to optimize operations, enhance patient outcomes, and improve overall experiences.

Payer services we offer

Utilization management

Ensuring the appropriate and efficient use of medically necessary healthcare resources, services, and treatments while optimizing administrative processes and costs.


Our comprehensive approach with custom healthcare payer solutions enables health plans to enhance operations and have fiscal oversight of their members’ services.

Automation of benefit discovery

Automate and auto-populate the database of members to efficiently retrieve relevant information and details across various systems, eliminating manual data retrieval and streamlining the process for customer advocates and their teams.

Clinical decision support systems

A decision engine that analyzes and determines the auto-approval or need for further review of service requests, expediting the decision-making process and addressing potential data gaps upfront to optimize efficiency and minimize the involvement of high-cost resources.

Role-based visualization

Within our healthcare payer solutions, our solution aggregates data and access control, allowing users to access specific data sets that pertain to their role, thereby increasing the accuracy of decision-making.

AI in auth process

Artificial intelligence presents a natural fit where outdated human decisions can be automated through ML models trained on established criteria. This scalable and agile approach reduces administrative costs and optimizes workflow to improve member satisfaction.

Care management

Delivering patient-centered quality care by leveraging data insights to ensure that patients/members receive appropriate and timely care to prevent their healthcare costs from escalating.


Our comprehensive solution manages and determines the most suitable next steps, personalizing care delivery, cost containment, and enhancing patient outcomes throughout the healthcare journey.

Characterization

Utilizing valuable insights from large amounts of data to assist healthcare professionals in timely intervention and personalized care, improving efficiency, and enhancing communication to prevent further complications.

Case management solutions

Our case management solutions prioritize health conditions and streamline patient routing, eliminating the need to outsource specialized services. We coordinate efforts, guide decision-making, and integrate seamlessly with payer enrollment for a more efficient healthcare management process.

AI in predictive risk stratification

Leveraging the power of AI to generate risk scores and recommend timely intervention and prioritize resources to improve patient engagement, reduce unnecessary utilization, and improve outcomes.

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Claims matching

Enabling claims matching by integrating authorization and claims data to ensure accurate payments. This guarantees healthcare organizations are accurately paying for the services they authorized.


Our comprehensive healthcare payer solutions perform checks and balances to validate claims, bridging the gap between utilization management and claims systems.

Simplification process

Automating claims processing by streamlining workflows and creating configurable exception handling based on the organization’s unique needs. This increases the efficiency of adjudicating claims by only showing relevant information.

Personalize dashboards

Provide custom screens for financial services unit to identify and address pending claims, enhancing decision-making efficiency.

Data manipulation/data processing

Validating claim data against utilization management systems/authorization systems for accuracy and consistency, eliminating manual effort and human error.

Clinical decision support

Automating clinical decision-making processes to provide agile capabilities to clinicians in specialty chronic condition management, like Oncology, Diabetes, etc. Eliminating the complexity and challenges associated with rules engine configuration by creating a single and reliable source of truth for medical necessity.


The clinical decision support system as a consolidated source ensures data consistency and accuracy across any healthcare organization, streamlining and simplifying the authorization process at scale.

Authorization and regimen management

Facilitating authorization processes to manage multiple regimens and approval criteria across diverse health plans, ensuring accuracy and variation evaluation prior to making a decision.

Lifecycle tool

Enabling initial shell authorization with collected data and running it against member benefit eligibility and other decision factors.

Decision engine tool

Streamlining the workflow process for regimens approval by cross-checking them against pre-approved criteria of each health plan, considering traditional treatment plans, drug approvals, and alternatives prior to automating a decision.

Auditable/review component tool

Oversight of workflow to validate regimen variations during the authorization process. The tool provided a mechanism for auditing changes and their impact across the organization.

Payer case studies

Awards & recognitions
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Payer insights

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