Self-Funded Employers
As a self-funded plan sponsor, every dollar overpaid on medical claims directly impacts your company’s bottom line. Traditional TPA reporting and sample-based audits leave significant money on the table. claimswatch.ai acts as your independent post-payment watchdog to identify overpayments and recover capital.
Key Employer Benefits
- 100% Claim Scrutiny: We don't guess with 5% or 10% sample sizes. After applying financial threshold filters, we audit 100% of your remaining claims.
- Zero Operational Burden: We interface directly with your TPA or claims processor to ingest data securely through our Client Portal.
- No Disruption to Employees: Our audits are performed strictly post-payment. Employee benefits, doctor visits, and active care are completely untouched.
- Fiduciary Protection: Satisfy your ERISA duties with clear, documented oversight of paid claim accuracy.
Consultants & Brokers
Your clients rely on you for innovative cost-containment strategies. Adding claimswatch.ai to your service matrix gives you a powerful differentiator that uncovers hidden cash for your clients, validates TPA performance, and strengthens client retention.
Why Advisors Partner With Us
- Actionable Reporting & Dashboards: Access dynamic narrative summaries, audit timelines, and graph-based reporting through our secure web portal to present directly to clients.
- 20+ Years of Industry Expertise: Founded by long-standing industry veterans who have managed claims audits for major self-funded groups across Michigan.
- Turnkey Client Onboarding: Our web portal guides your clients step-by-step through data uploads, validation, and project timelines with minimal handholding needed from your team.
Union Trusts
Trustees have a strict fiduciary duty to safeguard trust dollars and ensure every health claim paid accurately reflects fund plan parameters. claimswatch.ai brings over two decades of experience helping major union trust funds identify systemic overpayments and restore capital to the plan.
Tailored Audit Solutions for Union Funds
- Plan Parameter & Eligibility Enforcement: Verify that paid claims strictly adhere to trust rules regarding visit limits, excluded procedures, chronic condition parameters, and active member enrollment windows.
- Coordination of Benefits (COB) & Medicare: Uncover instances where Medicare, ESRD, or another primary plan should have paid first.
- 100% Claim Analysis: Trustees get complete peace of mind knowing that all claims meeting dollar thresholds are checked—not just a random sample.
Third Party Administrators (TPAs)
Claims adjudication systems process millions of complex transactions daily. Even the most advanced engines experience minor leakage due to provider billing updates, complex COB scenarios, or fee schedule drift. claimswatch.ai works collaboratively alongside TPAs as a secondary line of defense to validate accuracy and recover overpaid claims.
How We Complement TPA Operations
- Automated Data Ingestion: TPAs can upload standard layout claim files securely through our structured web portal with automated data quality verification.
- Targeted Rule Analytics: High-speed engines flag complex systemic issues including duplicate payments, multiple procedure payment reductions (MPPR), and incorrect coding.
- Client-Controlled PHI Lockdown: Configured access windows (60–120 days) automatically revert all PHI back to an encrypted state once project review is complete.
CFOs & Internal Auditors
Healthcare claims represent one of the largest un-audited line items on corporate balance sheets. Traditional auditing methods relying on statistical sampling leave significant overpayments undetected. claimswatch.ai gives financial executives complete fiscal transparency through rigorous, 100% claim auditing post-payment.
Key Financial & Audit Highlights
- Zero Sampling Risk: By analyzing 100% of claims above baseline dollar thresholds, we uncover systemic error patterns that standard sample-based audits miss.
- Measurable ROI: Identify overpayments across 6 primary domains: Payer Errors, Provider Errors, Other Payer Liability, Eligibility, CMS Standards, and Plan Parameters.
- Enterprise Security: Client-controlled encryption keys and automatic PHI expiry ensure full regulatory compliance.