Claims Audit

Your contracts hold the answers.
Replay every claim against them.

Traditional audits sample a fraction of claims and miss systematic errors. Replay historical claims against your contract logic. Surface every underpayment. Explain every denial. Full traceability to the clause.

Claims Audit
Your Claims
Verifying...Complete
Audit complete
All claims verified
8
Error patterns
$1.4M
Recoverable
Sample verification dashboardFull audit trail
Coverage
All claims
vs 5% sampling

Systematic errors hide in plain sight.

Payment errors repeat across hundreds of claims because they follow contract logic that was loaded wrong or never updated. Sampling catches a fraction. Full verification catches the pattern.

Hospitals

Rate escalator drift

Contract says 3% increase effective Jan 1. Payer system still on prior-year rates through June. Every matching claim underpaid for months.

5+ months
typical lag before rates load
Self-Funded Employers

Stale rate schedule

January renegotiation with new network discounts. TPA still adjudicating on old rates through Q1. Variance compounds across thousands of claims.

~4%
variance on in-network claims
Value-Based Care

Attribution gap

Mid-year TIN change excluded active patients from panel. Settlement calculated on reduced attribution, reducing shared savings by hundreds of thousands.

60 days
typical dispute window

These aren't one-off mistakes. They're patterns that repeat until someone checks.

From contracts to verified claims.

Your contracts become executable logic. Every historical claim runs through it. Underpayments, denials, and errors surface with the clause that explains them.

1
Ingest contracts
PDFs, fee schedules, SPDs, amendments
// Hospital contract
Rate:115% Medicare MPFS
Escalator:3% annual, Jan 1
Carve-out:Implants > $2K
// Self-funded SPD
Network:PPO, -42% inpatient
Stop-loss:$175,000 specific
Rx tier:4-tier formulary
2
Translate to logic
Every clause becomes executable
// Generated verification rules
function verifyEscalator(claim) {
const rate =
base * 1.15 * escalator(claim.date);
return claim.paid >= rate;
}
3
Verify every claim
Payments, denials, and determinations
29881Hospital OP
$1,805.23
99215E&M Visit
$187.40
J0881Infusion
Denied
27447Knee Repl.
$24,180.00
12,847 claims processed617 variances · 43 wrongful denials
Findings with evidence
Every variance and denial explained
Escalator not applied§3.1
$412K
Wrongful denial (CO-50)§4.2
$318K
Carve-out missed§7.3
$189K
Full claim-level detailExport ready
2-4 weeks
Typical timeline
Payments + denials
Complete claims picture
Full traceability
Every finding to a clause

What the contract logic reveals.

Underpayments, wrongful denials, and systematic errors. Each one repeats silently until the underlying logic is checked.

Rate escalator drift
Hospitals
Wrongful denial pattern
Hospitals
Stop-loss aggregation gap
Self-Funded
Policy-to-system lag
Payers
Attribution error
VBC

Relative frequency from historical audits. Actual findings vary by contract type and payer.

Every finding traces back to the contract.

No black boxes. Each underpayment shows the clause and the math. Each denial shows whether the contract says it should have been paid.

Claim under review
CPT
29881 (Knee arthroscopy)
Contract
BCBS-2024 §3.1
Expected
$1,805.23
Paid
$1,487.00
Applicable contract clause
§3.1Rate Escalator

"Reimbursement rates shall increase by 3% annually, effective January 1 of each contract year, applied to the then-current fee schedule."

Verification applied
Expected payment
$1,752.65×1.03=$1,805.23
Actual payment
$1,487.00 (prior-year rate)
Underpayment
$318.23
Verification failed
Escalator not applied, payer still on 2023 rates
Recoverable
$318.23
Contract: §3.1Rule: ESCALATOR_2024
View full audit log

This pattern repeated across 847 CPT codes for this contract

Total recovery: $412,000

The right moment for an audit.

Most teams start with a historical review at a natural inflection point.

Renewal approaching
47 days
Escalator drift$412K
Fee schedule mismatch$267K
Carve-out missed$189K
Documented leverage$868K

Contract renewal

Enter negotiations with documented errors and concrete recovery data, not estimates.

Dispute ready
VBC settlement gap
$1.2Mvs payer settlement
Attribution: 847 patients excluded
Benchmark: stale trend factor
Dispute window: 60 days

Settlement disputes

Build a case with claim-level evidence and contract references before the dispute window closes.

Vendor complianceIssues found
Network rates (TPA)
Variance
Stop-loss aggregation
Variance
Rx formulary tiers
Variance
Copay/coinsurance
Compliant

Vendor validation

Verify your TPA or administrator is following your contract terms, not their interpretation of them.

Audit
Recover & Appeal
Monitor

Two files. Two weeks. Real answers.

No integrations. No system access. See every underpayment, every wrongful denial, and the contract evidence behind each one.

You provide
Contract or SPD
Pricing terms, fee schedules, amendments
Claims data
CSV, remittance files, or standard export
Time to share< 1 day
2-4 weeks
You get
Identified recoveryQuantified
All in scope
Verified
Traceable
To contract clause
Full audit trail
Contract clause references
Denial analysis
Export-ready

Start with one contract. See real findings in weeks, not months.