Providers

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Delivering patient-centric care is a prevailing focus for providers, but administrative tasks, technology and process inefficiencies, and a lack of clear and comprehensive patient data can often get in the way. Our team has decades of experience working alongside providers — modernizing systems to alleviate burdensome processes and making improved patient outcomes possible. We provide powerful services and solutions supported by unmatched expertise to ensure opportunities for efficiency and eliminate barriers to high performance.

We are passionate about delivering what matters most to those who can make the most impact.

Reduce Complexity, Improve Lives

Enhancing outcomes

Reducing friction

Optimizing cost efficiencies

How We Can Help

Our modular solutions are purpose-built for providers — optimizing processes, improving cost efficiencies and elevating care quality.

The Gainwell team is deeply knowledgeable, and our systems set the standard for provider optimization. We can help accelerate claims processing, support value-based care and control escalating costs while orchestrating workflow and task management.

Care Management

Improve quality and reduce the total cost of care with our interoperable Care Management platform — built on a foundation of automation, standardization and mature processes and using data from renowned, industry-standard COTS products like the Johns Hopkins ACG® System as well as administrative and clinical information.

Clinical Claim Reviews

Identify coding, location, level of service and reimbursement errors pre- or post-pay. Our Clinical Claim Reviews solution uses artificial intelligence to select the claims most likely to have errors and clinical expertise to compare them against medical records.

EDI Clearinghouse

Simplify provider billing with comprehensive validation rules for managed care and fee-for-service transactions and ensure your encounter data is compliant through a single point of submission.

Eligibility Verification

Verify member eligibility while providing clarity on the decision to staff — ensuring they can explain, with sensitivity, why someone is ineligible.

FraudCapture®

Gain end-to-end support in the identification of fraud, waste and abuse. Our modular, cloud-hosted platform exposes issues through clear visualization and easy-to-navigate exploration tools.

Payment Analytics

Pinpoint claims that have been improperly billed or paid while minimizing abrasion in the process. Our Payment Analytics solution uses proprietary data analysis tools to compare claims history across many criteria that client systems or claim processors often miss.

Post-Payment Recovery

Capture and recover dollars lost as a result of improperly paid claims. Our Post-Payment solutions leverage AI and machine learning to ensure accuracy in the claims review process and efficient, digital processes to pursue recoveries and maximize savings.

Pre-Payment Solutions

Maximize cost avoidance for your plan or program. Our tenured market expertise pairs with our end-to-end COB solutions to amplify speed to delivery and provide truly actionable insights.

Prior Authorization Rules Engine

Automate and expedite authorizations for your state with configurable rules and workflows designed to improve member and provider satisfaction.

Provider Solutions

Create new efficiencies within provider management processes, from initial enrollment through final determination letters to support participation in fee-for-service and managed care programs.

Utilization Management

Validate the appropriateness and necessity of services and procedures to contain costs in your plan or program. Utilization Management addresses your most pressing needs by combining cost management with accurate pre- and post-payment claim reviews and prior authorization from our Clinical Care Reviews.

We can help. But the next move is yours!

Please fill out the information below to start a no-pressure chat with one of our knowledgeable solutions experts.

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