How It Works

Health Claims Workflow

Flow of authority from insured client to facility — each stakeholder validates claims before reimbursement is finalized.

Step 1

Health Client

You, the employer.

Step 2

Claims Hedge

Flanked by Stop-Loss Carriers (left) and Underwriters (right).

Step 3

Claims Adjudicator

Facility Negotiator / Claim Auditor ↔ TPA (Third Party Administrator).

Step 4

Hospital Facility

Care delivered — payment traceable to a benchmark and a margin.

The Claims Layer

Every claim reviewed before payment — not after the money is gone.

Comprehensive claim auditing

Licensed healthcare professionals review every claim for billing errors, medical appropriateness, and egregious pricing.

Pre-claim negotiation

Pricing agreed before care where possible, using objective industry data and the provider's actual cost plus a fair margin.

ERISA appeal management

Structured, compliant handling of provider disputes.

Member advocacy

A staffed team your employees call instead of HR, guiding them through bills, questions, and provider communications.

Balance bill defense & legal support

If a provider pursues a member for amounts above the fair Cost-Plus payment, we defend it. Advocacy, audit, and litigation resources stand behind every claim.

Flexible engagement models

Each option includes defined rate caps, so your exposure is known in advance.

Post-claim auditing and advocacy

Pre-claim negotiation plus auditing and advocacy

Claim-specific auditing and advocacy

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