Insurance Claims Analytics

Insurance claims analytics is a solution that transforms raw claims data into actionable business insights for insurance companies by leveraging machine learning, predictive modeling, and real-time data processing to identify fraud patterns, optimize claims processing workflows, predict claim costs, and improve risk assessment accuracy.
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Garner Health

Garner Health

5.0 (5)
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Finally, a platform that solves the challenge of delivering accurate and comprehensive provider referrals. Garner DataPro serves referrals based on the most detailed provider performance and directory data in the industry.
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Springbuk

Springbuk

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3,000,000

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Springbuk Health Intelligence is built on a foundation of scalable data automation. We have standard data models to support data integration across all types of employee benefit programs - from claims and eligibility... Show More
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Wellnecity

Wellnecity

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2,500 eligible

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330,000

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Wellnecity's Smart Hub transforms your self-funded health plan into a high-performing asset by effortlessly integrating key vendors and various point solutions, ensuring transparency and accountability.

Wellnecity’s Smart Hub integrates member-level... Show More
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Cotiviti

Cotiviti

5.0 (1)
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Founded

2004

Employees

8,573

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About Cotiviti

Cotiviti is a leading solutions and analytics company that is reshaping the economics of healthcare, helping its clients uncover new opportunities to unlock value. Cotiviti’s solutions are a critical foundation for healthcare payers in their mission to lower healthcare costs and improve quality through higher performing payment accuracy, quality improvement, risk adjustment, and network performance management programs. The company also supports the retail industry with data management and audit services that improve business outcomes. Show More
Budgie Health Inc.

Budgie Health Inc.

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200,000

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Use our underlying analytics engine to model endless plan design and contribution scenarios and evaluate the employee-level financial impact. Show More
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Meeko Health

Meeko Health

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Founded

2023

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0

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1.9M Seed Round

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About Meeko Health

Meeko is shaping the future of how we think about treating mental health. Meeko is an employer sponsored benefit that allows employees access to root cause focused mental health care using FDA approved Psychedelic-assisted therapy.

Our licensed provider network is available nationwide for in-person integrative mental health care which is accessible through our portal with support from a care navigator. Our app and platform are designed for the best outcomes tracking to be sure members receive top behavioral health results for their wellness so companies profit on a productive team. As a brand, we focus on educational... Show More
Nayya

Nayya

4.7 (5)
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Founded

2019

Employees

130

Funding Summary

105.7M Series C

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About Nayya

The New Era in Employee Benefits.
Inspired by the end-employee. Powered by data. Join us in revolutionizing the way consumers experience group benefits.

Nayya drives benefits impact from enrollment to usage to re-enrollment. Nayya delivers on this impact through:
- Data infused personalization — bringing together data in order to surface hyper-relevant guidance at scale
- Optimized benefits spend — holistic solutions that balances healthcare needs and value with financial affordability
- Digital engagement expertise — drive ultimate benefit impact through intuitive, timely member experiences

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Sedgwick

Sedgwick

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Founded

1969

Employees

33,000

Funding Summary

4B Angel Round

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About Sedgwick

Sedgwick brings comprehensive claims and productivity management solutions to a wide range of American businesses, from local employers to global corporations with U.S. roots. We offer the broadest array of integrated services available in the industry, delivered by our experienced, knowledgeable and dedicated colleagues in 80 countries around the globe. From our humble beginnings as a regional TPA in 1971, Sedgwick has grown to more than 33,000 professionals meeting the needs of North American businesses.
Our operational structure is divided into regional business units to ensure that each program is supported strategically by a senior-level management resource. Each... Show More
Verifi1

Verifi1

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15,000

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Our Medical and Pharma Claims Process uses AI technology to review claims, learn patterns in claims files and develop responses to help employers reduce their retrospective claims expense. We can also review claims... Show More
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Wellworks For You

Wellworks For You

4.1 (44)
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250,000

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Claims analytics answers the question every CFO asks: what is the program worth. Wellworks connects medical claims, biometric outcomes, and engagement data into a single client-specific analysis and delivers it through interactive Microsoft... Show More
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Reclaim Health

Reclaim Health

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1,000 eligible

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1,500,000

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Reclaim’s AI-powered, claims-driven healthcare financial advocacy solution delivers year-round monitoring of all claims (small and large) and provides human-supported proactive financial advocacy, claims-driven benefits recommendations, and robust claims data analytics.
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Benefitfocus

Benefitfocus

3.4 (4)
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Integrated benefit claims data for analytics to help shape, manage and measure benefit strategy. Includes services to identify claim errors and recover overpayments on behalf of the plan sponsor. Show More
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Bluespine

Bluespine

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1,200,000

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PlanGuard transforms medical and pharmacy claims data into continuous, actionable intelligence for self-funded employers. By analyzing 100% of healthcare spend against each employer's unique plan terms, provider contracts, pricing agreements, and payment rules,... Show More
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Covert

Covert

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70,000

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Covert is a claims analytics and opioid-risk prevention program for self-funded employers, health plans, PBMs, and TPAs. Our patent-pending algorithm analyzes pharmacy claims to detect withdrawal and escalating opioid risk months before abuse... Show More
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finHealth

finHealth

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5,000 eligible

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1,500,000

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Our software solution analyzes in real-time 100% of medical and pharmacy claims, providing timely and actionable insights to prevent erroneous payments, drive cost savings and quality improvements while simultaneously upholding the employer's fiduciary... Show More
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Lumelight

Lumelight

5.0 (1)
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100 eligible

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1,000,000,000

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Lumelight's medical and pharmacy claims audit services are designed to uncover what dollars are being spent on for self-insured benefits plans. Our processes provide a detailed review of claims data to confirm that... Show More
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Benefits Claims Intelligence LLC

Benefits Claims Intelligence LLC

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Founded

2019

Employees

4

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About Benefits Claims Intelligence LLC

Benefits Claims Intelligence (BCI), based in Memphis, TN, provides healthcare claims auditing for self-insured employers, municipal/government plans, insurance trusts, and state Medicaid programs. Its Integrity Analysis Platform uses machine learning and rule-based logic to examine 100% of a plan's claims transactions, applying 30+ analytical checks to identify billing errors, duplicate payments, upcoding, and mental health parity gaps. Clients typically recover 2-8% of annual claims spend. Offers ongoing real-time monitoring, recovery support with legally defensible documentation, and compliance guidance covering ERISA, PHSA, CAA, and HIPAA. Show More
PlanYear

PlanYear

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Founded

2022

Employees

13,000

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About PlanYear

PlanYear is a comprehensive benefits solution built for benefits consultants, employers and employees throughout the benefits lifecycle. We help benefits consultants scale their workflows, empower employers to make their mark, and elevate employee experience. Show More
Sterling Wellness Solutions, L.L.C.

Sterling Wellness Solutions, L.L.C.

3.1 (6)
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Founded

2001

Employees

50

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None

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About Sterling Wellness Solutions, L.L.C.

At Sterling Wellness Solutions, we believe that health and well-being are the foundation for a fulfilling life. Our total approach to employee wellbeing provides innovative and personalized solutions that empower individuals and organizations to achieve their health goals. We are committed to a holistic approach that considers the physical, mental, and emotional aspects of health, and we believe that preventive care is key to a healthy lifestyle. Our values of integrity, empathy, collaboration, and accountability guide us as we create a culture of wellness that inspires individuals to take control of their health. With our expertise and support, we strive... Show More
HealthLock

HealthLock

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HealthLock Enterprise

HealthLock protects employees and employers from rising healthcare risks and costs by uniting fraud protection, cost navigation, and post-care advocacy in one platform. The result is proactive protection,... Show More
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Frequently Asked Questions

What is Insurance Claims Analytics?

Insurance claims analytics is a data analytics platform that uses machine learning and predictive modeling to analyze claims data, detect fraud, optimize processing workflows, and provide actionable insights to improve insurance operations.

What Types of Fraud can the System detect?

These platforms usually identify various fraud patterns including staged accidents, inflated medical bills, duplicate claims, identity theft, provider fraud, and suspicious billing patterns through automated anomaly detection and machine learning algorithms.

What Data Sources does the Platform integrate with?

These tools integrate with core insurance systems, medical databases, third-party data providers, government databases, and external fraud detection networks to provide comprehensive analysis.

Are these Solutions compliant with Regulatory Requirements?

Yes, these solutions include built-in compliance reporting for HIPAA, state insurance regulations, and other relevant standards, with audit trails and data governance controls.

How does Predictive Modeling improve Claims Management?

Predictive models forecast claim costs, identify high-risk cases early, predict settlement outcomes, and recommend optimal handling strategies to improve efficiency and reduce costs.

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