Claims Repricing

Analyze out-of-network claims, apply cost-up and median reimbursement methodologies, and recommend optimal repricing

Healthcare payors processing hundreds of thousands of claims daily face a critical bottleneck in out-of-network repricing. Manual repricing analysts must evaluate each claim against complex methodologies—cost-up analysis for facility claims, median reimbursement calculations for practitioner claims—while referencing provider history, geographic cost indices, and contractual allowances. This labor-intensive process creates backlogs, inconsistent pricing decisions, and delayed provider payments that strain network relationships. This agentic workflow automates the end-to-end repricing pipeline. The orchestrator ingests incoming out-of-network claims, classifies them by claim type (facility vs. practitioner), and routes to specialized sub-agents. A Cost Analysis Agent applies the appropriate methodology—cost-up for facilities using Medicare cost reports and charge-to-cost ratios, or median reimbursement for practitioners using regional benchmarks. A Compliance Validator ensures each repriced amount meets regulatory requirements and contractual terms before a Payment Router finalizes the output. Organizations deploying automated claims repricing report 60-80% faster processing throughput with 15-25% improvement in savings per claim. The consistency of algorithmic repricing also reduces provider appeals by 30-40%, as pricing decisions are defensible and transparent. This is critical for any payor or TPA handling significant out-of-network volume, where repricing accuracy directly impacts both margins and provider relationships.