Stop the Payer Shenanigans
Payers exploit clinical justification requirements to deny payment and create administrative waste. It's time we put clinical decision making back in the hands of the clinicians.
Clinical Justification, noun phrase
clin·i·cal jus·ti·fi·ca·tion
1. A favorite tactic used by Healthcare Payers to deny or delay payment for services. Typically requires medical professionals to explain clinical decision making to bureaucrats and administrators.
See: Medical Necessity, Level of Care, Prior Authorization, DRG Downgrades
Clinical Justification, noun phrase
clin·i·cal jus·ti·fi·ca·tion
1. A favorite tactic used by Healthcare Payers to deny or delay payment for services. Typically requires medical professionals to explain clinical decision making to bureaucrats and administrators.
See: Medical Necessity, Level of Care, Prior Authorization, DRG Downgrades
Payers Are Lining Their Pockets
Payers treat Clinical Justification like a game, requiring Providers to explain their medical reasoning to insurance administrators to receive reimbursement.
For Payers, the more complex the Clinical Justification, the less they have to pay out.
For Providers, the bureaucracy is so burdensome many simply give up.
How We Help
As healthcare operators, we know there's never just one solution for the complex problems we face. This is not a game. That's why we've developed a variety of solutions to address the unique needs of unique health systems and providers.
The Engine
Our Generative AI engine combines clinical care guidelines, contracts, historical payer behavior and other relevant sources to define exactly what clinical justification is required for each treatment and service.
Tools
Leveraging our AI engine, we offer software products to prevent denials and recover revenue tied to clinical justification requirements.
Experts in Utilization Management provide immediate impact at organizations looking for cost and revenue improvements.
And yes, we use our own AI software to drive results. That's how we know they're awesome.
Managed Services
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A Better Way
We’re combining our new technology with a group of expert practicioners, a Provider consortium, and a novel business model to address the clinical justification imbalance through payer accountability.
People
We've brought together a group of people passionate about addressing the inequity in the current Payer-Provider relationship. Our clinicians, technologists, and healthcare operations experts offer a very different team than what you're used to getting from VC backed healthcare technology startups.
Community
Our growing community of Health Systems and Physicians share Payer behavior with The Engine to ensure the community benefits from the largest, and most current, repository of published and unpublished Payer rules.
Aligned Incentives
Our financial alignment guarantee is included in every customer contract ensuring that we can operate transparently and share in cost reductions and performance improvement.
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Get in touch
How We Help
As healthcare operators, we know there's never just one solution for the complex problems we face. That's why we've developed a variety of solutions to address the unique needs of unique health systems and providers.
Our Generative AI engine combines clinical care guidelines, contracts, historical payer behavior and other relevant sources to define exactly what clinical justification is required for each treatment and service.
Managed Services
Experts in Utilization Management provide immediate impact at organizations looking for cost and revenue improvements.
And yes, we use our own software so the outcomes are significant.
Leveraging our AI engine, we offer software products to prevent denials and recover revenue tied to clinical justification requirements.
Tools
The Engine