HEADLINE PARTNER
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.
PLATINUM PARTNER
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.
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.
GOLD PARTNERS
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™.
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.
Carelon
Website: https://www.carelon.com/
The health of the healthcare system improves when spending is responsible and accurate. Today, platform technology and advanced analytics are paving the way to make that more efficient and more proactive than ever before. Backed by decades of experience, Carelon’s Payment Integrity solutions bring together breakthrough technology and human expertise to help speed your ability to drive cost savings and value for your stakeholders.
CoventBridge
Website: https://coventbridge.com/healthcare-fwa-solutions/
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:
- Centers for Medicare and Medicaid Services managing the Unified Program Integrity Contractor program investigating Healthcare FWA since 1997
- One of the largest government agencies providing a national network of undercover investigators
- 700 National licensed employee investigators, many of which are former OIG, DOJ, FBI 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
EXL
Website: https://www.exlservice.com/
EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world’s leading corporations in industries including insurance, healthcare, banking and others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have over 57,000 employees spanning six continents. For more information, visit www.exlservice.com.
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 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/
MedReview sets itself apart with over 50 years of experience delivering physician-approved pre-pay and post-pay payment integrity services that prioritize billing and payment quality, accuracy, and precision. Every claim reassigned by MedReview is reviewed, approved, and documented by a team of physicians, resulting in the industry’s lowest appeal overturn rate.
Utilizing proprietary technology combined with extensive subject matter clinical and administrative expertise, we achieve a 40% or greater reassignment rate focused on our clients’ specific needs. MedReview provides the full spectrum of payment integrity solutions including DRG and clinical reviews, cost outlier audits, re-admission reviews, data mining and itemized bill reviews.
Partnered with clients across the country, MedReview offers a flexible approach, supporting both complete outsourcing and supplemental enhancements to existing programs. By optimizing recoveries, preventing overpayments, and improving the provider experience, MedReview empowers payors to navigate the complexities of payment integrity with confidence and measurable success.
Rialtic
Website: https://www.rialtic.io/
Rialtic is a next-generation platform that equips and enables players with the technology to take control of and execute their payment accuracy strategy. Rialtic’s first solution on the platform is a comprehensive code editing capability that combines the scope of editing typically found with both primary and secondary editors and merges it into a single platform supported by a modern user experience for managing policies, deviations, reporting, and provider inquiries. Our solution champions transparency — enabling greater understanding and control of your payment accuracy program and empowering payment accuracy teams to collaborate more effectively within their organization and with provider partners and employer groups.
Community Partner
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.
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.
Nokomis
Website: https://nokomishealth.com/
Nokomis was founded in 2013 by our current CEO Rich Henriksen to ensure Claim Accountability and make a difference in the healthcare system.
We are still privately owned and therefore only have to answer to our customers - that’s the way we like it.
Through 35 years in healthcare, Rich and his team compiled their deep and broad knowledge to build Nokomis and its proprietary technology, ClaimWise™. This unique technology finds patterns in claim data to identify claims for further review, regardless of dollar amount. Combined, ClaimWise™ and the Nokomis team intelligently select claims for review, finding errors even in claims that look fine at face value.
Performant Healthcare Solutions®
Website: https://www.performantcorp.com/home/default.aspx
Performant Healthcare Solutions® is a leading independent provider of technology-enabled audit, recovery, and analytics services in the United States with a focus in the healthcare payment integrity industry. Performant Healthcare Solutions® works with healthcare payers through claims auditing and eligibility (coordination of benefits)-based services to identify improper payments. The Company’s commercial health plan clients include both national and regional payers that represent more than 100 million covered lives across all lines of business, including commercial, Medicare, and Medicaid coverages. Performant Healthcare Solutions® also supports numerous engagements with the Centers for Medicare & Medicaid Services, including multiple Recovery Audit Contractor contracts and the Medicare Secondary Payer Commercial Repayment Center contract, as well as a contract with the US Department of Health and Human Services, Office of the Inspector General for complex claim review nationwide. The Company also features a call center to serves clients with complex consumer engagement needs.
Powered by a proprietary analytic platform and workflow technology, Performant Healthcare Solutions® also provides professional services related to the recovery effort, including reporting capabilities, support services, customer care, and stakeholder training programs meant to mitigate future instances of improper payments. Founded in 1976, Performant Healthcare Solutions® is headquartered in Livermore, California. Visit www.performanthealthcare.com and follow us on Twitter: @PerformantCorp.
Shift Technology
Website: https://www.shift-technology.com
Shift Technology empowers health plans to strengthen payment integrity with precision, fairness and speed at critical steps of the claim lifecycle. With a continually optimized concept library, enriched data, and advanced, healthcare-trained AI, Shift detects and helps plans prevent errors and improper payments to maximize savings. Our SaaS-based solutions drive accelerated and insightful decision-making, helping health plans reduce costs and enhance operational efficiency.
SILVER PARTNER
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.
Codoxo
Website: www.codoxo.com
Codoxo’s mission is to make healthcare more affordable and effective for everyone and serves as the premier provider of artificial intelligence-driven solutions and services that help healthcare companies and agencies proactively detect and reduce risks from fraud, waste, and abuse and ensure payment integrity. Codoxo’s Unified Cost Containment Platform helps clients manage costs across network management, clinical care, provider coding and billing, payment integrity, and special investigation units. Our software-as-a-service applications are built on our proven Forensic AI Engine, which uses patented AI-based technology to identify problems and suspicious behavior far faster and earlier than traditional techniques. Our solutions are HIPAA- compliant and operate in a HITRUST-certified environment. For additional information, visit www.codoxo.com.
Lyric
Website: https://www.lyric.ai/
Lyric is a platform-based healthcare technology company, committed to simplifying the business of care by preventing inaccurate payments and reducing overall waste in the healthcare ecosystem. Lyric, formerly ClaimsXten, is a market leader with 35 years of pre-pay editing expertise, dedicated teams, and top technology. Our solutions leverage the power of technology and advanced analytics to maximize value. Discover more at Lyric.ai.
Exhibitor
CAQH
Website: https://www.caqh.org/
CAQH is a leading organization focused on aligning the healthcare ecosystem around essential solutions, creating a more connected and less costly experience for all. For more than 20 years, CAQH has partnered with millions of providers, thousands of health plans, state Medicaid agencies, and leading healthcare stakeholders who leverage the organization's solutions, operating rules, and insights to connect and exchange data every day as a part of the business of healthcare. Learn more at CAQH.org.
HealthEdge
Website: https://healthedge.com/
Innovating a world where healthcare can focus on people, HealthEdge® is driving a digital transformation through a single digital ecosystem that delivers advanced automation and clinical engagement among healthcare payers, providers, and patients. The next-generation healthcare SaaS company provides an integrated ecosystem of advanced solutions for core administration (HealthRules® Payer), payment integrity (HealthEdge Source™), care management (GuidingCare®), and member experience (Wellframe™) that empower health plans to accelerate business, reduce costs and improve outcomes. Learn more at HealthEdge.com and follow us on LinkedIn.
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.
Vālenz Health
Website: https://www.valenzhealth.com/
Vālenz® Health is the platform to simplify healthcare – the destination for employers, payers, providers and members to reduce costs, improve quality, and elevate the healthcare experience. The Valenz mindset and culture of innovation combine to create a distinctly different approach to an inefficient, uninspired health system. With fully integrated solutions, Valenz engages early and often to execute across the entire patient journey – from care navigation and management to payment integrity, plan performance and provider verification. With a 99% client retention rate, we elevate expectations to a new level of efficiency, effectiveness and transparency where smarter, better, faster healthcare is possible.
Zelis
Website: https://www.zelis.com/
Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.
Media Partners
The Healthcare Data
Website: https://thehcdata.com/
The Healthcare Data is an information-centric website that is dedicated to the healthcare industry online. Our platform serves as a comprehensive B2B resource, offering a wealth of valuable information to professionals and enthusiasts within the healthcare sector. Whether you are a healthcare provider, researcher, industry expert, or simply someone interested in staying informed about the latest developments, we have everything you need.
