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(Pronounced "Claim-Chee")
AI-Powered Claims Intelligence
Identifying Improper Claims Payments
That Payers are Missing Today
ClaimQI™ deploys a patent-pending machine learning and large language model to identify claim patterns and Fraud, Waste & Abuse in healthcare payments that go beyond today's traditional systems. ClaimQI identifies financial leakage that legacy systems & processes simply can't see.
New eBook:
Medicare Supplement at a Tipping Point
There exists a long-standing assumption with Medicare Supplement carriers that they pay when Medicare pays. Medicare payment alone is not evidence that a claim met Medicare's coverage rules.
CMS found 6.55% of Fee-for-Service payments, $28.8B, to be improper in 2025. And when Medicare suspends a fraudulent provider, the Medicare portion is held while the supplemental portion is often still paid.
Proud to share our newest eBook crafted in collaboration with White Pine Actuarial. Read about opportunities Med Supp carriers have to reduce claims costs, lower loss ratios, and improve Med Supp profitability, rate stabilization and member affordability.
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$300B+
Lost annually to healthcare fraud, waste & abuse in the U.S.
Source: NHCAA / CMS estimates
~10%
Of all healthcare spending is lost to FW&A, the majority paid before detection.
Source: CMS, FBI Healthcare Fraud Division
<1%
Of fraudulent claims detected by traditional rule-based payer systems
Source: OIG / industry research
Legacy systems alone leave dollars unrecovered
Today's Payers are Flying Blind
Medicare Plans and TPAs rely on legacy rules engines and retrospective audits. By the time fraud is detected, the money is already gone. In addition, only a fraction of improper payments
(otherwise known as waste & abuse) are being identified and/or properly explained
to support recovery efforts.
Rules engines lack sufficient scale and intelligence
THE PROBLEM
TPAs lack Intelligent infrastructure and information
Claims navigation lacks pin-point accuracy and detail
ClaimQI Claims Intelligence
Delivers Real Payer Value
Our Value
10-15%
Reduced Fraud, Waste & Abuse that reaches payment
amount varies by Recovery and/or Prevention programs purchased and maturity of legacy programs
25-50x
Return on Investment
ROI varies by one or more programs purchased and representative of claims programs to date
+10-20%
Paid Waste & Abuse claims recovered
Improve health plan profitability
Lower claims cost and medical loss ratios to improve net income
Improve affordability & competitiveness
Improved loss ratios means better consumer pricing and a more competitive market position
Improve health plan profitability
Lower claims cost and medical loss ratios to improve net income
Improve affordability & competitiveness
Improved loss ratios means better consumer pricing and a
more competitive market position
Reduce administrative burden
Explainable AI improves recovery efforts & reduces provider abrasion
Amplify fraud detection
Intercept and stop losses before they occur to protect from future losses, with explainability
Reduce Administrative Burden
CMS compliance & audit documentation
Simplify audit-ready trails for program integrity, reviews & reporting
Recovery queue prioritization
AI-enabled queue ranking, citations and explanations maximize ROI on recovery programs