Why the old model no longer works.

The payment integrity industry has run on the same playbook for thirty years: rule-based, single-point, adversarial, slow to onboard, opaque to audit. Here is what replaces it.

Five pillars. One platform.

P · 01

Pre-Pay Intelligence

"Stop the bleeding before it starts — every dollar flagged pre-adjudication is a dollar saved permanently."
For: CFOs · Medical Directors
P · 02

Post-Pay Recovery

"Systematic, provider-friendly recovery that recaptures what pre-pay couldn't catch — without the abrasion."
For: Payment Integrity Teams
P · 03

Coding Validation

"Clinical precision at the code level — ensuring every claim reflects the actual care delivered."
For: Clinical Operations · Compliance
P · 04

Payment Accuracy

"Contractual accuracy, fee schedule alignment, and duplicate detection across every payer relationship."
For: Finance · Operations
P · 05

Executive Intelligence

"Board-ready analytics that transform payment integrity from a back-office function into a strategic asset."
For: C-Suite · Board
Competitive Disruption

Why the old model no longer works.

The payment integrity industry has operated on the same playbook for thirty years. ClaimReturn was built to replace it.

At a glance
ClaimReturn Legacy vendors
Coverage Integrated lifecycle Single-point solution
Detection AI-native, retraining monthly Static rule libraries
Provider experience Collaborative · low abrasion Adversarial · high abrasion
Time to first ROI First billing cycle 12 – 18 months
Audit trail Per-flag clinical rationale Black box output

  1. Integrated lifecycle, not point solutions

    Legacy vendors own one piece — pre-pay or post-pay or coding. ClaimReturn connects all three into a continuous feedback loop.

  2. AI-native, not rules-based

    Static rules catch only what they were written to catch. Our ML models surface anomalies no rule could anticipate, trained on your specific population.

  3. Provider-friendly, not adversarial

    Traditional recovery creates friction that damages network relationships. Our collaborative model preserves provider trust while achieving superior recovery rates.

  4. Fast ROI, not slow onboarding

    Most enterprise payment integrity platforms take 12 to 18 months to show results. Our model delivers measurable savings in the first billing cycle.

  5. Transparent intelligence, not a black box

    Every flag, every recovery, every recommendation comes with a full audit trail and clinical rationale.

What buyers ask

Answers before you ask.

The questions a TPA executive, payer, or self-funded employer should expect from any payment integrity partner — answered honestly, with no marketing in the way.

How does ClaimReturn work alongside our existing TPA?
We integrate with your TPA at the claims-feed layer. The TPA continues to administer your plan; ClaimReturn runs in parallel to surface pre-pay flags and post-pay recoveries. No member experience changes, no claim routing changes, no re-papering of provider contracts.
Is our data HIPAA-protected end-to-end?
Yes. All claims data is encrypted in transit and at rest. We sign a Business Associate Agreement with every covered entity before any PHI is exchanged. Access to identified data is restricted to authorized clinical reviewers operating from U.S.-based, access-controlled environments.
How long until we see measurable savings?
Our implementation model targets first-cycle savings within ninety days of data ingestion. The initial leakage assessment is typically delivered inside thirty days, followed by the first pre-pay flags and post-pay recovery queue inside sixty.
What if we already have a payment integrity vendor?
Most clients we onboard have one. We are designed to operate alongside existing rule-based or post-pay-only vendors and surface what those systems are missing. After the first ninety days, the comparison is usually obvious — at that point clients choose to consolidate or to keep us layered as a second-pass system.
How do you keep provider abrasion low?
Every flagged claim comes with clinical rationale and audit trail before it reaches the provider. Recovery conversations start from a defensible position, not a denial letter. Our measured abrasion rate runs under 0.1% — roughly eight times below the industry norm — because providers can see why a claim was flagged and respond with documentation rather than dispute.
What does the lift look like on our side?
A standard data feed (one-time setup), one steering-committee call per month, and access to your contract and fee-schedule library. No platform to learn, no dashboard to maintain. Executive reporting is delivered to your team — it does not require your team to operate.
How are findings defended against provider appeals?
Every flag carries a per-claim audit trail: the rule or model output, the clinical rationale, the documentation cited, and the reviewer responsible. When a provider appeals (through this site or directly), our clinical team responds with the full defense package. Appeal-overturn rates run below industry medians.