Health Claims Workflow
Flow of authority from insured client to facility — each stakeholder validates claims before reimbursement is finalized.
Health Client
You, the employer
US Risk Group
Flanked by Stop-Loss Carriers (left) and Underwriters (right)
Claims Adjudicator
Facility Negotiator / Claim Auditor ↔ TPA (Third Party Administrator)
Hospital Facility
Care delivered and billed
What Happens at the Claims Layer
Every claim passing through the plan is reviewed before payment — not after the money is gone. Our audit and advocacy program includes:
Comprehensive claim auditing
Licensed healthcare professionals review every claim for billing errors, medical appropriateness, and egregious pricing.
Pre-claim negotiation
Pricing agreed before care where possible, using objective industry data and the provider's actual cost plus a fair margin.
ERISA appeal management
Structured, compliant handling of provider disputes.
Member advocacy
A staffed team your employees call instead of HR, guiding them through bills, questions, and provider communications.
Balance bill defense & legal support
If a provider pursues a member for amounts above the fair Cost-Plus payment, we defend it. Advocacy, audit, and litigation resources stand behind every claim.
Flexible engagement models
Post-claim auditing and advocacy
Pre-claim negotiation plus auditing and advocacy
Claim-specific auditing and advocacy
Each option includes defined rate caps, so your exposure is known in advance.