InsurTech · Payment integrity and TPAs
Every claim checked. Every flag explained.
For insurers and the administrators who serve them: claims checked before payment, patterns found after it, and every flag explained, so people can decide quickly and fairly.
The health data members share with their twin never touches a claim decision.
The integrity engine
Five stages, one explainable engine.
Payment integrity is moving from recovering money after payment to preventing errors before it. Averra is built for that shift. Checks are written and kept current with coders, clinicians, pharmacists and investigators, alongside models calibrated to each insurer’s members, network and contracts. The newest techniques are tagged on each stage, and people make every clinical and fraud decision.
01 · Ingest
Claims, records and contracts, structured
- Claims, invoices, pre-approvals and medical records
- Scanned documents read, and checked for alteration
- Each insurer’s policy wording, contracts and tariffs
02 · Check
Before payment, inside adjudication
- Cover, limits, pre-approvals and other liable payers
- Coding, clinical, tariff and package edits
- Policy changes drafted into rules, approved by experts
03 · Detect
Patterns no single claim reveals
- Outliers against case-mix-adjusted peers
- Links between providers, prescribers, pharmacies and members
- Shifts in coding, frequency, severity or documents
04 · Decide
People make the call
- Rule, evidence and policy side by side
- Record summaries that cite the source page
- Clinicians and investigators decide on cases, not alerts
05 · Learn
Every outcome sharpens the next check
- Reviewer and appeal outcomes tune every check
- After-payment findings become before-payment checks
- Providers shown what to fix, so errors stop
Detection library
Eight families of checks, tuned to your policies.
Each insurer’s policy wording, benefits, contracts and tariffs are loaded, so a check means exactly what your policy means. Most findings are errors, not fraud, so each one is classed as error, waste, abuse or fraud before anyone acts.
Cover and eligibility
- Member covered on the date of service
- Benefit limits, co-payments and waiting periods
- Services that differ from what was pre-approved
- Other insurers or liable third parties that should pay
Coding and clinical validation
- Code combinations that should not be billed together
- Diagnoses or severity the record does not support
- Payment groups raised by unsupported diagnoses
- Procedures or quantities that do not fit the patient
Hospital stays and itemised bills
- Items already covered by room or theatre charges
- Drugs and supplies billed but not recorded as given
- Stays longer than the condition usually requires
- Admissions that could have been day cases
Prices and contracts
- Charges above the contracted tariff
- Packages split into separate charges
- Items billed on top of an inclusive package
- Implants and devices priced above invoice
Duplicates and overlaps
- Exact and near-duplicate claims
- One service billed by more than one provider
- Resubmissions after rejection without new evidence
- Overlapping inpatient, outpatient and home care
Medicines
- Prescriptions without a supporting diagnosis
- Early refills, duplicate therapies and excess quantities
- High-cost therapies without pre-approval
- Prescribers and pharmacies out of line with peers
Identity and documents
- Providers without a valid licence or registration
- Services dated after a member’s death
- Member identities shared or borrowed
- Invoices, reports or prescriptions altered or generated
Patterns and networks
- Providers out of line with case-mix-adjusted peers
- Referral and prescribing loops between linked parties
- More services billed than a working day allows
- Services billed but not received, confirmed with consenting members
Explainable by design
Every flag, explained.
A reviewer sees why a claim was held, the evidence behind it and what the policy says, in one view. Providers get the same explanation, so disputes are settled on facts.
- Rule, evidence and policy, side by side. No black boxes, and nothing to take on trust.
- Fair to providers. Benchmarks adjusted for case-mix, so you challenge an expensive provider, not an expensive population.
- One step to act. Pay at the contracted rate, request records or refer to investigation, with every action logged.
- People decide. Averra holds, explains and prepares the evidence. A clinician or investigator makes the call.
Inside your claims flow
Embedded in adjudication. Answerable to your team.
Averra is designed to run inside your claims flow, not beside it. Each claim is checked as it is processed and returned with one of four outcomes: pay, correct, request records or refer, each with its reason. Nothing in your core claims system is replaced, and every rule is yours to approve.
Start here
A retrospective review
A secure transfer of historical claims. Nothing connects to your live systems.
Then
After payment
Scheduled files of paid claims, reviewed for patterns and recoveries.
When you are ready
Before payment
A real-time connection inside adjudication that returns pay, correct, request records or refer, each with its reason.
Trust by architecture
A firewall between care and claims.
The health data members share with their twin is never used to price, decide cover or decide a claim. Payment integrity runs only on the claims, records, contracts and tariffs an insurer already holds.
Care
The member’s twin
Wearables, home tests and the records members choose to share.
- Wearables
- Home tests
- Health records
Used for care, and nothing else.
Claims
Payment integrity
The claims, contracts and tariffs an insurer already holds.
- Claims
- Contracts
- Tariffs
Used to pay what should be paid.
For third-party administrators
From pre-approval to payment, in one flow.
Administrators carry the busiest part of health insurance. Averra is designed to work inside your administration as an agentic layer, under each client’s brand and rules, from pre-approval to payment.
Pre-approve
Requests checked against policy and clinical criteria. Clear cases approved promptly; the rest go to clinicians with the evidence.
Intake
E-claims, scanned invoices and medical reports read and structured. Eligibility and duplicates checked; unclear fields go to people.
Adjudicate
Each insurer’s benefits, limits, co-payments and agreed tariffs applied. Clean claims pass straight through; exceptions show why.
Check
Fraud, waste and abuse checks before payment. Every flag carries its reason; suspected fraud goes to investigators.
Pay
Approved claims paid and reconciled against insurer funding, with remittance advice explaining every amount.
Report
Each insurer gets its own dashboards, service levels, data feeds and a complete audit trail.
Serve, at every step. Prime Assist answers members and providers on phone calls, WhatsApp, iMessage and in-app chat, in their language, and hands over to named people with the full transcript.
Built for administrators
Many insurers, one way of working.
- Every insurer, its own rulebook. Wordings, benefits, tariffs and reports configured per insurer, versioned by effective date and tested before release.
- Straight through where it’s safe. Clean claims and clear requests pass without a touch. Everything else reaches the right person with the reason it stopped.
- People make the hard calls. AI reads, checks and prepares. Clinicians and assessors decide exceptions and clinical questions, and every override is recorded.
- Service levels you can see coming. Queues, ageing and turnaround tracked per insurer, with early warning before a service level slips.
- Members and providers answered. Prime Assist handles claim status, pre-approval updates, documents and bookings, with full transcripts.
- Audit-ready, data kept apart. Every decision logged with its evidence and rule version, and each insurer’s data kept separate.
Governed and measured
Run like a regulated function. Measured like one.
- Validated and monitored. Models validated against reviewer decisions, monitored for drift and documented for audit.
- Every rule versioned. Rules, models and policy configurations held in one inventory, with effective dates and signed-off changes.
- Oversight that is real. Reviewers have the authority and the expertise to change the outcome.
- Fair appeals. A written rationale citing the policy or contract, and appeals reviewed by someone other than the original reviewer.
What we report, per check and per insurer
Payment integrity
- Hit rate for each check
- Overturn rate for each check
- Savings that hold after appeal
- Prevention, avoidance and recovery, reported separately
- Days to recover
- Provider friction
Claims operations
- Straight-through rate
- First-pass accuracy
- Pend rate and touches per claim
- Turnaround, direct billing and reimbursement
- Pre-approval turnaround
- Service levels for each insurer
- First-contact resolution
- Appeal overturn rate
Questions
Payment integrity, in brief.
What does Averra check before a claim is paid?
Cover, benefit limits and waiting periods; whether the claim matches what was pre-approved; other insurers or liable third parties that should pay first; coding and clinical validation; contracted tariffs and packages; itemised hospital bills; duplicates; and whether the diagnosis supports the service or medicine. Clean claims flow straight through. Anything else is held with the reason and the evidence.
How does Averra find fraud that no single claim reveals?
By looking across claims: providers out of line with case-mix-adjusted peers, links between providers, prescribers, pharmacies and members, more services billed than a working day allows, and altered or generated documents. Where members consent, Prime Assist can confirm that a billed service was actually received.
Who makes the final decision on a held claim?
A clinician or investigator with the authority to change the outcome. Averra holds the claim, explains why and prepares the evidence. Routine administrative checks, such as cover on the date of service, follow each insurer’s rules and are explained in the same way. Every decision is logged.
Is member health data used for payment integrity?
No. Payment integrity runs on the claims, records, contracts and tariffs an insurer already holds. The health data members share with their twin is never used to price, decide cover or decide a claim.
What happens when a provider disagrees?
They see the same rule, evidence and policy the reviewer saw, and can appeal. Appeals go to someone other than the original reviewer, and overturned findings are traced to their root cause so the check improves.
How is success measured?
By savings that hold after appeal, not savings identified. Prevention, avoidance and recovery are reported separately, with hit and overturn rates for every check, all measured on your claims and signed off by your actuary.
Does Averra work with our existing claims system?
Yes. There are three ways in, and you can start with the first: a secure transfer of historical claims for the retrospective review; scheduled files of paid claims for review after payment; and a real-time connection inside adjudication that returns pay, correct, request records or refer, each with its reason. Nothing in your core claims system is replaced.
How does Averra support a TPA serving several insurers?
Each insurer’s policy wording, benefits, tariffs, rules and reporting are configured separately, versioned by effective date and tested before release. Your team works one way, and every client keeps its own rules, data and audit trail.
How are false positives kept down?
Checks are adjusted for case-mix and benchmarked against peers, records are requested only when the chance of error is high, every flag shows its evidence, and hit and overturn rates are tracked for every check, so weak checks are tuned or retired.
See it on your own claims.
Start with a retrospective review of your historical claims, under a data processing agreement. Savings are measured on your claims and signed off by your actuary.