Clinical Negotiation
Efficiently getting provider sign-off on reductions to minimize balanced billing and maximize savings.
Cost Reduction
Provider Agreements
Combining human intelligence and innovative technology to help resolve issues before payment.
Claritev goes beyond standard editing solutions by identifying and resolving clinical waste and abuse before medical bills are paid. Unlike vendors that rely solely on automation, we use machine learning to prioritize inventory, proprietary actuarial analytics to flag the highest-risk claims, and a dedicated provider portal to streamline communication.
Errors identified can include:
Unlikely combination of procedures
Unusual services reported
Excessive services reported over time
This technology is paired with licensed, board-certified physicians, nurses, and medical coders who review suspect charges and confirm errors. Together, these capabilities can uncover issues traditional tools may miss, such as unlikely procedure combinations, unusual services, and excessive utilization overtime. They can also help secure provider sign-off on reductions, helping clients avoid erroneous payments without the potential burden of post-pay recovery.
Claritev Clinical Negotiations can help enable:
Savings by identifying inaccurate billing.
Provider abrasion minimization.
Balancing billing mitigation through provider sign-off.
Pay and chase elimination.
Clarity by resolving issues others miss.
Making Our Impact Clear
40%
Average Success Rate
73%
Average Savings Rate
33%
Charges Scored with Evidence and Abuse
Creating clarity through clinical negotiations.
Clients’ out-of-network and non-contracted medical claims with charges over $2,000 and Claritev in-network and contracted claims with charges over $2,500 are automatically routed to the solution, where the following occurs.
01 Case Selection
Our case-identification technology uses physician-and coder-informed actuarial analytics, built on more than 18 million code combinations, 90 service areas, to score high-risk claims and identify potential waste or abuse in 33% of charges reviewed.
02 Case
Review
Charges are reviewed by licensed, board-certified physicians or coders with deep experience in audits, adjudication, and appeals. They work to identify errors that automated tools cannot detect and, when needed, can engage in clinician-to-clinician dialogue to help build provider confidence and cooperation.
03 Case Resolution
Our reductions are achieved by trained negotiators and extend beyond simply removing disputed charges. Providers ultimately sign off on our reductions, virtually eliminating balance billing of members. We deliver an average 40% success rate with claim savings averaging 73% on successfully negotiated charges.
How Claritev can create a competitive advantage.
We involve clinicians at every step, including daily claim reviews and provider appeal support.
We integrate clinical review to confirm complex issues prior to recommendation.
We have over four decades of pre-pay experience — most claims returned within 24 hours.
We contract with over 1.2 million practitioners and facilities; with an appeal rate of 3%, we minimize provider abrasion.
With our long-tenured focus on non-contracted claims, we see the most creative billing schemes.
We are HITRUST certified with nearly 300 payers depending on us for pre-payment integrity services.
Engaging insights.
Claritev insights, resources, and case studies.
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How can Claritev help enable savings through clinical negotiations?
Learn how Claritev can help you improve payment accuracy and eliminate wasteful spending.