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Healthcare Insurance · 5 min read

Claims Adjudication: The Decision Made 500 Million Times a Year That Most Plans Still Get Wrong

A large health plan adjudicates hundreds of millions of claims annually. Payment errors average 3 to 7 percent of total claims spend. Each manual review touch costs $15 to $25. The economic case for AI-assisted adjudication is not an efficiency argument. It is an accuracy and scale argument — and the two compound each other.

12 May 2026 Claims Adjudication Payment Accuracy

Healthcare Insurance · 5 min read

HCC Coding Accuracy: The Revenue That Exists in the Clinical Documentation You Already Have

Each missed Hierarchical Condition Category costs approximately $80 to $100 per member per year in Medicare Advantage revenue. On a population of 100,000 members, closing 5 percent of coding gaps is worth $4 to $5 million annually. The documentation that supports those codes already exists in the clinical record. The gap is between the documentation and the submitted risk code.

12 May 2026 HCC Coding Risk Adjustment

Healthcare Insurance · 5 min read

Healthcare Fraud Detection: Why Paying First and Recovering Later Is a Strategy That Does Not Work

Industry estimates put Fraud, Waste, and Abuse at 10 to 15 percent of total healthcare spend. Pre-payment detection is five to ten times more cost-effective than post-payment recovery. Most health plans still detect the majority of fraud after the claim is paid. The shift to pre-payment detection is not a technology preference. It is an economic imperative.

12 May 2026 Fraud Detection FWA

Healthcare Insurance · 5 min read

High-Risk Member Identification: The Three-Month Lag That Costs Health Plans Billions

Claims-based risk identification tells a health plan which members were high-cost last quarter. Predictive risk stratification tells them which members will be high-cost next quarter. That three-month difference is the window for proactive intervention. A preventable hospital admission costs $12,000 to $20,000. The care management contact that prevents it costs a fraction of that — but only if it happens before the admission, not after.

12 May 2026 Care Management Risk Stratification

Healthcare Insurance · 5 min read

Member Disenrollment: The Decision to Leave Is Made Before Open Enrollment Opens

Acquiring a new health plan member costs between $500 and $1,500. A 1 percent reduction in disenrollment on a population of 200,000 members is worth $1 to $3 million in retained premium revenue. Most health plans detect disenrollment after it happens. The behavioral signals that precede it are visible 60 to 90 days before open enrollment.

12 May 2026 Member Retention Disenrollment Prediction

Healthcare Insurance · 5 min read

Member Enrollment: When the Wrong Member Joins at the Wrong Price

The first-year Medical Loss Ratio on a newly enrolled member cohort is the clearest indicator of whether the acquisition strategy is working. Most health plans cannot predict that number accurately at the point of enrollment. The data to do so exists. The models to use it do not yet sit at the enrollment decision.

12 May 2026 Member Enrollment Risk Scoring

Healthcare Insurance · 5 min read

Provider Network Management: The Performance Variation Your Contracts Are Not Capturing

Provider cost and quality variation within a health plan network is substantial and systematic. A high-performing primary care physician prevents significantly more avoidable hospital admissions than a low-performing one with an equivalent patient panel. Most health plans monitor a small fraction of their network for performance outliers. The rest remains invisible.

12 May 2026 Provider Network Performance Monitoring