The Undeniable Payment Integrity Choice

Healthcare payment integrity was built on a premise that no longer matches modern reality: waiting months for claims to clear, paying vendors a 20% to 30% contingency fee on recoveries, and shipping sensitive patient data across external clouds to find errors that should have been caught before payment was made.

Paytegrity was founded to invert that model.

We engineered PayRight℠ from the ground up as a native, non-intrusive prepayment operating system that sits directly between core adjudication and final check-run. Instead of vendor dependency, we give health plans and program integrity teams sovereign control over their own audit logic, clinical determinations, and financial recoveries—all operating 100% within their private cloud perimeter with zero PHI egress.

What We Deliver
We bridge the gap between regulatory rule rigor and modern data velocity. Our architecture unites hundreds of deterministic clinical and coding audit procedures with explainable clinical artificial intelligence:

• Inpatient & Outpatient Clinical Governance: Full-spectrum MS-DRG, APC, and facility validation. We evaluate principal diagnosis sequencing, procedure selection, CC/MCC integrity, and medical records using evidence-grounded AI to verify physician orders, operative reports, and discharge summaries without black-box guesswork.
• Contract Rate Governance: An automated reimbursement waterfall that digitizes complex provider contract terms—evaluating per diems, case rates, and fee schedules against Chargemasters and MRFs to eliminate rate leakage.
  
• Specialized High-Cost Spend Programs: Purpose-built audit modules covering Behavioral Health & Substance Use Disorder (ASAM level validation), Skilled Nursing (PDPM), Home Health (PDGM), and high-cost specialty biologicals.
  
• Investigative & FWA Launchpad: An analytical workbench designed to profile anomalous billing velocities, impossible-day service patterns, and provider billing outliers—transforming raw claim feeds into actionable investigative leads and defensible case dossiers.
  

Where We Are Going
We believe the next era of payment integrity belongs to teams that own their rules and retain 100% of their savings.

While legacy vendors debate incremental adjustments to post-pay recovery services, we are continuously pushing the boundaries of what payment defense looks like:

Advancing from batch staging to sub-second, in-memory analytical pipelines that evaluate hundreds of thousands of claim lines without placing a footprint on core adjudication systems.

Expanding from private health plan prepayment overlays to national-scale program integrity frameworks capable of profiling syndicate risk and protecting public healthcare trust funds.

We built Paytegrity for organizations ready to lead rather than react. We provide the algorithms, the sovereign architecture, and the clinical precision. Together, we own the rules, protect the spend, and define what comes next.