For Payers · Health Plans · TPA & Managed Care Orgs
Peerbits delivers technology built for the financial, clinical, and regulatory complexity of payer organizations — from commercial insurers and Medicare Advantage plans to TPAs and self-insured employers managing population health at scale.
Compliance & Standards
The Payer Burden
Health plans face compounding pressures from every direction — regulatory scrutiny, rising medical costs, provider disputes, and member expectations that grow faster than administrative capacity. The organizations winning in this environment have one thing in common: they've automated what their competitors still do by hand.
The federal government estimates $100B+ in improper Medicare and Medicaid payments annually. Commercial payers face the same problem: duplicate billing, unbundling, upcoding, and coordination-of-benefits failures that leak millions in claims overpayments — most of which are never detected or recovered.
CMS finalized new PA rules in 2024 mandating 72-hour turnaround for urgent requests and 7 days for standard. Manual PA processes averaging 3–5 days per request put plans at direct regulatory risk — with member harm and appeals costs compounding the exposure.
Medicare Advantage plans rated below 4 Stars forfeit CMS quality bonus payments worth hundreds of millions per year. Most plans losing Star points lose them on the same measures: medication adherence, preventive screenings, chronic care management, and CAHPS member experience — all addressable through technology-driven member engagement.
Payers are legally required under the No Surprises Act and CMS interoperability rules to maintain accurate, FHIR-accessible provider directories and share clinical data with members and providers via standardized APIs. Most health plans' provider data is 20–30% inaccurate — creating coverage disputes, network leakage, and regulatory penalties.
Nine integrated modules covering the complete payer operational lifecycle — from claims adjudication and fraud detection to member engagement, provider relations, and STAR performance management. Deploy one module or the full platform.
Automated claims processing with ML-based medical necessity review, code validation against payer fee schedules, bundling/unbundling detection, and real-time eligibility verification — reducing claims cycle time from days to hours.
Pre-payment and post-payment AI screening for duplicate billing, upcoding, unbundling, phantom billing, and coordination-of-benefits failures — trained on payer-specific historical claims patterns and updated with emerging fraud schemes quarterly.
AI-driven PA processing with FHIR-native provider submission portal, real-time clinical guideline matching (InterQual, MCG), auto-approval for clearly eligible requests, and CMS 72-hour/7-day rule compliance dashboards.
Learn moreReal-time STAR measure tracking across all Part C and D domains, care gap identification at member level, automated outreach for medication adherence and preventive screenings, and HEDIS data collection automation — closing gaps before the measurement period ends.
AI-personalized member communications across SMS, email, IVR, and app push — for care gap outreach, chronic disease management, medication reminders, CAHPS survey optimization, and network steering toward high-value providers.
FHIR R4-compliant provider directory with automated accuracy verification, credentialing status monitoring, network adequacy analysis, No Surprises Act compliance reporting, and provider portal for real-time directory attestation.
Hierarchical Condition Category (HCC) risk score optimization, chronic disease registry management, predictive hospitalization risk modeling, and value-based contract performance reporting across ACO, MSSP, and commercial VBC arrangements.
Automated EOB generation, provider payment dispute management, fee schedule contract management, remittance advice automation, and provider-facing portal for real-time claim status, PA submission, and directory updates.
Automated HEDIS data collection, CAHPS survey administration, CMS interoperability API publishing, MLR reporting, Encounter Data Submission (EDS) validation, and state regulatory filing support — all in one compliance operations center.
Payer implementations fail when vendors treat health plans like generic software customers. We embed with your actuarial, claims ops, compliance, and IT teams — and configure every module to your benefit design, payer mix, and regulatory obligations before go-live.
STEP 1
Two-week structured discovery across claims, medical management, member services, and compliance to map current workflows and quantify the cost of each pain point in dollar terms.
STEP 2
FHIR R4 API connectivity, X12 EDI configuration, core admin system integration (FACETS, TriZetto, QNXT), and AI model pre-training on your claims history, fee schedules, and fraud patterns.
STEP 3
Live parallel run on a subset of claims or PA volume. AI decisions run alongside existing processes. Clinical reviewers and claims staff validate outputs before full automation is enabled.
STEP 4
Organization-wide go-live with dedicated Payer Success Manager, monthly MLR and STAR performance reporting, model retraining as your benefit designs and regulatory obligations evolve.
Compared to point solutions from Cotiviti, Cognizant TriZetto, Optum, Zelis, and Change Healthcare — Peerbits delivers a unified payer platform with AI-native claims intelligence, real-time FHIR interoperability, and deployment timelines that don't run 12–18 months.
| Capability | Peerbits | Cotiviti | Optum | Zelis | TriZetto |
|---|---|---|---|---|---|
| Unified Claims + FWA + PA Platform | Full Suite | FWA only | Siloed modules | Payments only | Claims only |
| FHIR R4/R5 Native Payer APIs (CMS Rule) | Compliant | No | Partial | No | In roadmap |
| Real-Time Pre-Payment FWA Detection | Pre + Post | Post-pay only | Yes | No | No |
| AI PA Automation (CMS 72hr Compliant) | 78% Auto | No | Manual review | No | Partial |
| STAR / HEDIS Real-Time Gap Management | Full | Retrospective | Yes | No | No |
| HCC Risk Score Optimization | 96.8% accuracy | Add-on | Yes | No | No |
| Avg. Go-Live Timeline | 90 Days | 9–12 Months | 12–18 Months | 4–6 Months | 12+ Months |
| Dedicated Payer Success Manager | Included | Add-on | Add-on | No | Add-on |
Measured Outcomes
Across 180+ payer deployments, Peerbits consistently delivers improvements across financial performance, regulatory compliance, and member experience — measurable within the first two quarters of go-live.
$940M
Cumulative FWA recoveries across active client base — spanning pre-payment intercepts and post-payment audits
91%
vs. industry average of 73%. Straight-through processing without human review — while maintaining 99.4% accuracy
78%
Up from an average 3–5 day manual turnaround. CMS 72-hour rule compliance maintained at 100% across all clients
0.8
Across Medicare Advantage clients deploying STAR management + member engagement in the same measurement year
3.4%
Average Medical Loss Ratio improvement driven by FWA recovery, PA accuracy, and clinical utilization management optimization
58%
Fewer disputes and faster resolution through automated EOB accuracy, real-time remittance advice, and provider portal self-service
96.8%
Correct HCC capture rate across attributed Medicare Advantage member panels — reducing risk adjustment audit exposure
90
Compared to 12–18 months for legacy payer platform vendors. Full FHIR integration and core admin system connectivity included
Regional carriers, Medicare Advantage plans, and TPAs share measurable outcomes from their first year with Peerbits.
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Learn more about our processes from our clients
After a rigorous selection process, choosing Peerbits as our technology partner was the right choice. Peerbits is an innovative company with a team of talented, committed, and smart individuals. Thank you for helping us deliver world-class healthcare solutions.
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In a 45-minute working session, our payer technology team will benchmark your current claims auto-adjudication rate, PA turnaround, STAR performance, and FWA recovery — and show you exactly where Peerbits moves the needle in your first two quarters.
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We serve commercial insurers, Medicare Advantage plans, Medicaid managed care organizations, TPAs, and self-insured employers. Our platform is configured for your line of business, regulatory environment, provider network, and existing core admin, claims, and clinical systems — whether you cover thousands or millions of lives.
Either approach works. Many health plans begin with a single high-impact capability — AI Claims Integrity, Prior Authorization Automation, Member Engagement & STAR Management, or Provider Data Management — and expand over time. All modules share a FHIR-native integration layer, so adding capabilities later does not require duplicate interfaces or manual data reconciliation.
We connect to core admin platforms, claims systems, provider portals, and clinical data sources via HL7 V2, FHIR R4/R5, CMS Patient Access and Provider Directory APIs, and CDS Hooks. PA determinations, claims edits, member outreach, and directory updates flow through standardized APIs — aligned with CMS interoperability and No Surprises Act requirements.
Most organizations go live in approximately 90 days, including payer operations discovery, FHIR and payer API configuration, a 30-day parallel pilot on a defined claim or PA population, and full rollout. Timelines depend on module scope, lines of business, and integration complexity, but our engagement model is designed for minimal disruption to active claims and authorization operations.
Point solutions address one workflow — FWA detection, prior auth, or member engagement — in isolation. Peerbits delivers a unified payer operations platform where claims integrity, PA automation, STAR gap closure, and provider directory management share the same data layer — reducing vendor sprawl and manual handoffs between administrative teams.
Every deployment is architected for HIPAA from day one: end-to-end encryption, role-based access controls, comprehensive audit logging, signed BAAs, and SOC 2 Type II controls. We align implementations with CMS interoperability rules, NCQA/HEDIS reporting needs, and your internal security policies. Member and claims data stays within your boundary — we do not use plan data to train shared models without explicit agreement.
Outcomes vary by module and baseline, but clients commonly report reduced improper payments and overpayment recovery, faster PA turnaround aligned with CMS timelines, improved STAR measure performance, and more accurate provider directories within the first 180 days. We benchmark KPIs such as claims leakage, PA cycle time, and quality bonus exposure during discovery and track them through monthly QBRs after launch.
Every engagement includes a dedicated payer success manager, ongoing regulatory and compliance updates, SLA-backed support, and monthly performance reviews. We also refine rules engines and AI models as your benefit designs, medical policies, provider contracts, and CMS requirements evolve — so accuracy and compliance improve over time.
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