You cannot look at every claim
Manual review scales with headcount, so it gets rationed. Everything outside the sample gets paid without a second look, and the sample rarely catches the claims that most deserved one.
Solutions / Payment Integrity
Payment integrity that
shows its work
Payment integrity is where a payer’s margin holds or slips. Most teams still work it as a sampled manual review after payment, backed by vendors who take a cut of whatever they find. PulseSync reads every claim before it is paid.
The problem
What gets
in the way
Findings arrive after the money has gone
Recovering money after payment costs more and works less often than catching it first. Every month between the payment and the finding drops your recovery rate.
Contingency pricing is misaligned
A vendor paid a percentage of what they find has every reason to keep finding things. You are renting a capability you should own.
How we solve it
What we do
about it
Every claim, not a sample
Eight agents read the same claim in parallel at adjudication. Every claim gets the same treatment, so nothing slips through on a sampling rule.
Each finding arrives with its evidence
A reviewer sees the line from the claim that triggered the flag, quoted, alongside the rule it broke. The decision takes seconds because the investigation is already done.
You set the bar
Confidence and exposure thresholds are yours. What clears them reaches a person, what does not is dispositioned and logged, and you can move the line whenever you want.
What you get
What changes
for your team
- Every claim is examined, not a sample of them
- Findings surface at adjudication, before payment, in seconds
- Each finding carries the data point that produced it, so a reviewer decides in seconds rather than investigating from scratch
- You set the confidence and exposure thresholds. What clears the bar reaches a person; what does not is dispositioned and logged
- The capability is yours. Pricing is not a share of findings
Why PulseSync
How it compares
Set against the way payment integrity is usually bought: a vendor that samples claims after they are paid.
| Typical payment integrity vendor | PulseSync | |
|---|---|---|
| What gets read | A sample of claims, after payment | Every claim, before payment, in seconds |
| What a finding looks like | A score or a flag | The rule it applied, the data that triggered it, and how confident it is |
| Who runs it | The vendor’s analysts | Your team, without a data science staff behind it |
| How accuracy is shown | A headline number | Measured on your own historic claims before anything is switched on |
| Getting started | An integration project | A file on day one, and 130+ connectors as you grow |
| What else it covers | Payment integrity only | Clinical review, stop-loss, and benefits and leave, on the same platform and data |
The agents
8 agents
do this work
Each one is trained, tested and audited on its own, built from the same skill library and governed the same way as everything else on the platform.
Who uses it
- Third Party Administrators Every claim read at adjudication, before it is paid, with the evidence for each finding
- Health Plans Eight detectors read every claim in parallel, pre- and post-payment, each finding carrying its evidence
- Brokers Large claims are read before they are paid, so what reaches the attachment point has already been checked
- Benefits & Leave Administrators If you also administer medical claims for the same employers, every claim is read before it is paid, on the same platform
Next step
See it on your
own data
We run your historic records through the agents and show you what each one finds, with its evidence, before anything is switched on.