PAYERS
Fewer errors. Lower costs. Simpler claims.
HealthWorks plugs into your existing systems to support complex claims above and beyond traditional billing.
The first-and-only platform that identifies all types of complex claims
- Motor Vehicle Collision (MVA) Coordination of Benefits
- Contract Compliance
- Out-of-Network Collections
- Medical Records Review
When claims stem from a motor vehicle or workers' compensation incident, a third-party liability carrier — not your health plan — should be primary. Most of the time, that distinction never gets made.
We identify claims before or after payment — and coordinate benefits with the liable carrier so your plan pays only what it should.
- Pre-pay and post-pay identification
- No patient contact
- No provider contact
- Limited data required
- Full coordination of benefits
Claims that belong to a third-party carrier stop flowing through your plan as if they don't. You pay less, your administrative cost goes down, and your provider and member relationships stay completely undisturbed.
One conversation can help show what this costs you.
Every contract your plan has negotiated represents a precise payment commitment. But between contract complexity, system limitations, and claim volume, what gets paid and what was agreed to often aren't the same thing.
We ensure every claim is adjudicated against what your contract actually says.
- Powered by Sleuth® — our proprietary contract compliance platform
- Pre-pay and post-pay claim analysis
- Contract term validation against actual payment
- Bundling and unbundling error identification
- No disruption to your existing adjudication workflow
When payment logic doesn't match contract terms, the difference comes out of your plan's budget. Sleuth® closes that gap — systematically, at scale, and before it compounds.
One review can show where your contracts stop being honored.
Out-of-network claims carry more complexity — and more risk of payment error — than any other claim type. Without a structured review process, payers routinely pay more than what the claim actually supports.
We validate out-of-network payments against what the documentation warrants.
- Pre-pay and post-pay OON claim review
- Payment validation against clinical documentation
- Identification of billing inconsistencies and overcharges
- No provider contact required
- Limited data required to get started
Accurate out-of-network payment isn't about paying less — it's about paying right. We give your plan the documentation and the process to do exactly that, without creating friction with your provider network.
One scan of your claims can show how much this is costing you.
High-dollar inpatient claims carry significant payment risk when the coded level of service doesn't match what the medical record actually supports. Without independent review, those discrepancies get paid — and stay paid.
We review the record and give you a defensible answer.
- Pre- and post-pay settings
- DRG validation for inpatient claims
- Clinical documentation review against coded level of service
- Identification of upcoding and unsupported complexity
- Expert findings with full documentation support
- No provider contact required during the review process
When a coded diagnosis or procedure doesn't align with the clinical record, the difference can be substantial. We surface it, document it, and give your team what it needs to act on it with confidence.
One conversation can help show what this costs you.
FAST START ASSESSMENT
Most of our customers are surprised by what a quick scan of their data reveals.
Our initial assessment can identify your recovery opportunity across every qualifying service line.
Common Questions
The questions providers ask us most — answered plainly.
How does HealthWorks integrate with our existing claims systems?
We work from standard claims data and layer onto your existing adjudication environment rather than replace it. Implementation is structured to minimize disruption to your current operations. We'll assess your specific setup in the early stages of an engagement to confirm compatibility and scope.
What is Contract Compliance Intelligence?
Sleuth® — our contract compliance engine — ingests your contract terms and payment logic and applies them against claims in adjudication — identifying where payments deviate from contracted rates, where bundling or unbundling errors occur, and where third-party liability should have been primary. It's designed to surface discrepancies at scale, not just on audited samples.
What does your medical records review service involve?
When a claim’s documented level of service is challenged or requires validation, our team reviews the supporting medical records to assess whether the coding and documentation align with what was billed. This is particularly relevant for DRG validation, complex inpatient cases, and high-dollar surgical claims. The goal is accurate payment — not blanket denial.
How does HealthWorks help with motor vehicle accident benefit coordination?
When a patient involved in a motor vehicle accident has their claim processed through health insurance, the liable auto insurer should typically be primary. We identify these cases, coordinate the benefits correctly, and pursue recovery from the liable party — reducing what your plan pays.
How does HealthWorks support Providers?
HealthWorks is not an advocate for either side — we're a payment accuracy platform. We help providers ensure claims are submitted correctly and completely. On the payer side, we help ensure claims are adjudicated accurately against contract terms. Both engagements are built around the same principle: billing accuracy reduces friction, cost, and dispute volume for everyone in the system. We maintain strict operational separation between our payer and provider work.
How do you handle data security and compliance?
We operate to the same security and compliance standards your own organization is held to. HealthWorks is fully HIPAA-compliant and executes a Business Associate Agreement with every client engagement — your data is protected health information and is treated accordingly. We are PCI DSS-compliant (Payment Card Industry Data Security Standard) for all payment-related data handling, and we maintain SOC 2 compliance — an independently audited framework that verifies our security controls, confidentiality practices, and system reliability are consistently upheld, not just designed on paper. For payer organizations specifically, SOC 2 Type 2 compliance means our controls have been tested over time, not just at a single point in audit. We are also TCPA-compliant (Telephone Consumer Protection Act) for any outbound communication workflows.
What is the typical return for a payer engagement?
It varies significantly based on your claim volume, contract complexity, and current payment accuracy baseline. The easiest way to assess your opportunity is to sample your claims data and give you a realistic estimate of where discrepancies exist and what financial recovery or prevention looks like.
Making healthcare work better.