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Pinpoint Claims Leakage. Quantify ROI. Strengthen Your Claims Operations for 2026.

A focused diagnostic workshop that reveals where your claims operations are losing money — and shows the financial lift you can unlock with Claims1™.
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The Problem (Why Payers Need This Now)

Every health plan knows leakage exists — few know where it originates or what it costs.
Industry data shows:
  • 1–3% of annual claims spend is lost to preventable overpayments
  • $25–$35 average cost for each claim touched in rework (CAQH Index)
  • 35% of pends trace back to timing and configuration sequencing issues
  • 12–18% interest penalties from delayed adjudication
  • 60–70% auto-adjudication rates in most plans vs. 85%+ benchmark
With 2026 regulatory pressure rising, plans need quantifiable insights — not guesswork.

The question isn't whether leakage exists.
It's where it hides.

Introducing The Claims Performance Assessment Workshop

A high-impact, expert-led assessment that evaluates your claims operations and delivers actionable insights, performance benchmarks, and a clear roadmap forward.

What We Ask For

A dataset review to ground the assessment in your real operations.
  • Your existing claims data
  • Your configuration exports
  • Your operational reports
  • Your post-payment behavior

What You Get

A deep, expert-led diagnostic of your operational, financial,
and configuration performance.
  • Pend Rate Analysis — root cause mapping tied to configuration, sequencing, and reconciliation behavior
  • Adjustment Hotspot Discovery — where edits, pricing rules, and coding interpretation create rework
  • Overpayment and Underpayment Drift — patterns linked to provider variability and structural gaps
  • Interest Exposure Quantification — timing drivers that could trigger 12–18% penalty accumulation
  • Auto-Adjudication Readiness — where configuration maturity restricts lift
  • Cross-LOB Leakage Mapping (if applicable)
  • Operational Impact Summary — mapped directly to staff effort, cycle times, and cost-to-serve
  • Prioritized Roadmap — quantified financial impact projections tied directly to Claims1™ capabilities
No major data lifts   |   No long prep cycles   |   No disruption to BAU
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Preview the Assessment Dashboard

Example visualization using sample data

This is the same style of dashboard you’ll receive as part of your executive readout, populated with your real claims and configuration signals. 

Instead of a static PDF, the workshop includes a dashboard preview built from dummy data to show what the assessment output looks like.
This gives you a clear view of the type of insights the assessment reveals — before we analyze your actual environment.

Your Assessment Dashboard Typically Includes:

  • Pend drivers and root-cause mapping
  • Overpayment and underpayment exposure visualization
  • Adjustment hotspot heatmaps
  • Interest accumulation curves
  • Auto-adjudication drift timelines
  • Configuration maturity scoring
  • Cross-LOB leakage comparison (if applicable)

Why This Assessment Is Different

Most “assessments” give you generic checklists or maturity scores. This one gives you financial clarity.

What sets it apart:

Minimal Lift for Your Team

We analyze your operating reality using the data you already have.

AI-Enhanced Correlation Mapping

Pattern recognition across thousands of pend reasons, edits, timing patterns, configuration values, and provider behaviors.

A Quantified
ROI Path

Each finding maps to measurable improvements achievable with Claims1™.

A True Diagnostic
— Not a Pitch Deck

You keep the insights even if you don’t implement Claims1™.

Zero-risk, fully applied, 100% usable.
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Who This Is For

The assessment is tailored to:

Medicaid Plans

  • Prompt-pay exposure
  • Encounter alignment
  • State-specific rules variability
  • Configuration drift in Medicaid benefit interpretation

Commercial / Exchange Plans

  • Provider disputes and abrasion
  • Claim timing issues triggering member dissatisfaction
  • Adjustment-driven operational backlog

Multi-Line Health Plans

  • Cross-LOB configuration issues
  • Shared rules misalignment
  • Enterprise leakage mapping
  • Auto-adjudication optimization

Claims Operations Leaders

  • Pend reduction
  • Version and timing alignment
  • Rework cost containment

Payment Integrity Teams

  • Overpayment drift
  • Recovery root causes
  • Preventable spend identification

Analysts and Configuration Engineers

  • Structural signal mapping
  • Timing and version readiness
  • Attribute-level consistency insights

What Payers Can Expect To Gain

Based on industry benchmarks and past engagements:
  • 15–25% improvement in auto-adjudication rates
  • 20–30% reduction in avoidable rework
  • 10–20% decrease in adjustment volume
  • Up to 35% reduction in pend categories
  • 3–5x ROI vs. pay-and-chase recovery methods
  • Significant mitigation of prompt-pay penalties
These are not aspirational — they are based on claims behavior patterns across real payer environments.

How the Workshop Works

Step 1: Kickoff

Define scope, confirm target LOBs, validate available data sources.

Step 2: Data Intake

You provide:

  • 2–3 months of claims extracts
  • Configuration export
  • High-level process reports
  • Common adjustment categories

Step 3: Analysis & Dashboard

Our Claims1™ experts apply analytical models to your data to map patterns and quantify exposure.

Step 4: Executive Readout

A live session walking through:

  • Key findings
  • Financial risk areas
  • Operational lift opportunities
  • Mapped Claims1™-powered improvements

Frequently Asked Questions (FAQs)

How long does the assessment take?

7–10 business days end-to-end. 

How much work is required from our team?

Minimal — we work primarily from existing data exports and configuration files. 

Is this tied to any regulatory program?

The assessment reflects conditions that affect compliance readiness, prompt-pay performance, and audit posture. 

Can this be applied across multiple lines of business?

Yes — the diagnostic can analyze commercial, Medicare, Medicaid, or a combination. 

Register Your Interest in the Claims1™ Performance Assessment

Once you submit the form, our experts will follow up to confirm scope, timelines, and what to expect from your assessment. No commitment required.

Sources:

This assessment framework draws on validated industry research, payer operations benchmarking, and real-world implementation patterns across health plans of all sizes. All statistics and operational insights used on this page are grounded in published studies, industry standards, and independent research.

  • CAQH Index, “2023 CAQH Index: Claims Payment and Administration,” CAQH Solutions, 2023.
  • McKinsey & Company, “Automating Healthcare Claims: The Path to 90% Auto-Adjudication,” 2022.
  • Black Book Market Research, “Claims Management Technology Survey: Payer Perspectives,” 2023.
  • Healthcare Financial Management Association (HFMA), “Best Practices in Claims Auto-Adjudication,” 2023.
  • American Medical Association (AMA), “Prior Authorization and Claims Processing Study,” 2022.
  • FICO, “Five Emerging Strategies for Healthcare Claims Processing in 2024,” 2023.
  • Experian Health, “State of Claims Report: Payer Segmentation Analysis,” 2024.
  • Premier Inc., “Healthcare Operations Benchmarking Report,” 2024.
  • Omega Healthcare, “Payer Trends Report: Scale Economics in Claims Operations,” 2025.
  • Multiple Industry Sources, “Claims Operations Economics: Size-Based Analysis,” 2024–2025.