Healthcare payers face growing pressure to control medical spending while maintaining payment accuracy and avoiding unnecessary disputes with providers. Recent CMS payment integrity data estimates $28.83 billion in improper Medicare fee-for-service payments, while Medicaid improper payments reached $37.39 billion. These figures include documentation and eligibility errors, not just incorrect reimbursement or fraud.
For health plans and TPAs, the challenge is identifying payment errors without adding unnecessary claim delays, administrative costs, or provider friction. Choosing the right partner means evaluating where it intervenes in the claims process, how it validates findings, and whether its services deliver measurable savings. This comparison examines 11 healthcare payment integrity companies across software, audit and recovery services, and outsourced operations to help buyers identify the right fit.
What Do Healthcare Payment Integrity Companies Do?
Healthcare payment integrity companies help health plans, TPAs, and government payers identify inaccurate claims, prevent improper payments, and recover overpayments. Their services include pre-payment claims editing, medical coding and clinical reviews, fraud detection, post-payment audits, coordination of benefits, and recovery.
Some providers offer software that flags errors before or after payment. Others conduct audits and manage recoveries, while operational outsourcing partners supply trained teams to review flagged claims, verify eligibility, and resolve outstanding cases. Depending on the services required, health plans may work with multiple providers across the claims lifecycle.
Top 10 Healthcare Payment Integrity Companies for 2027 Compared
| Company | Operating model | Claim stage | Best fit |
|---|---|---|---|
| Helpware | Dedicated payer operations teams | Claims processing, eligibility, flagged-claim review | Plans and TPAs needing staff in existing systems |
| Claritev | Pricing networks, software, services | Pre-pay and post-pay | Plans with complex out-of-network claims |
| Codoxo | AI and provider education platform | Pre-submission, pre-pay, FWA | Plans focused on preventing recurring billing errors |
| Cotiviti | Payment accuracy software and services | Pre-pay and post-pay | Large plans requiring both review and recovery |
| EXL Service | Analytics and managed operations | Pre-pay and post-pay | Payers combining analytics with review staff |
| Gainwell Technologies | Medicaid systems and services | Pre-pay and post-pay | Medicaid programs and state agencies |
| HealthEdge | Core administration and payment software | Primarily pre-pay | Plans embedding edits in adjudication |
| Machinify (includes Performant) | AI platform and recovery services | Pre-pay and post-pay | Plans combining audits, COB, and recovery |
| Optum | Payment integrity software and services | Pre-pay and post-pay | Plans seeking broad integrated capabilities |
| Zelis | Claims pricing, edits, and payment services | Primarily pre-pay | Plans and TPAs needing pricing and editing |
How We Selected Healthcare Payment Integrity Companies
We selected companies that provide healthcare payment integrity software, claims review, audit and recovery services, or operational support for payer payment integrity programs. Each provider has a defined service offering, an identifiable customer segment, and publicly available information about its capabilities and delivery model.
The list includes both technology providers and outsourcing companies because health plans may need software to identify payment errors and dedicated teams to investigate and resolve them. Helpware publishes this comparison and appears first; the remaining companies are listed alphabetically. The order does not indicate quality or performance.
For more on operational outsourcing providers, see healthcare BPO companies and claims processing companies.
Match the Vendor to the Claim Stage
Payment integrity programs often require several capabilities, from identifying claim errors to reviewing findings and recovering overpayments. Start by identifying where your operation needs support, then compare providers that address those specific problems.
| Problem to solve | Capability to evaluate | Illustrative providers |
|---|---|---|
| Findings and pended claims exceed staff capacity | Claims processing, eligibility verification, documentation, and review support | Helpware, EXL |
| Incorrect claims reach adjudication | Pre-submission education, pre-pay editing, and pricing | Codoxo, Lyric, HealthEdge, Zelis |
| High-cost or complex claims need validation | Clinical and coding review before payment | Cotiviti, Optum, Claritev, EXL |
| Overpayments are discovered after payment | Audits, recovery, coordination of benefits, and subrogation | Cotiviti, Machinify, EXL, Claritev |
| Suspected fraud needs investigation | FWA analytics, fraud detection, and case review | Codoxo, Gainwell, Optum |
Medicaid programs may also need state-specific third-party liability and audit capabilities from Gainwell. For post-payment comparisons beyond this list, Trend Health Partners received Best in KLAS awards in 2025 and 2026.
Healthcare Payment Integrity Company Profiles
#1 Helpware
Helpware supplies dedicated payer operations teams that work in clients’ systems rather than selling a claims editor or recovery platform. This makes it a potential complement to payment integrity software when findings, pended claims, or member inquiries exceed an internal team’s capacity. The buyer retains the underlying technology and program oversight.
- Services: Healthcare claims processing, insurance eligibility, COB checks, adjudication support, medical coding, flagged-claim documentation, and payer member services.
- Best for: Health plans, Medicare Advantage organizations, Medicaid plans, and TPAs needing dedicated operations capacity.
- Delivery: US, Puerto Rico, Mexico, Philippines, and other locations across 11 countries and territories.
- Security: SOC 2 Type II, ISO 27001, ISO 9001; company reports HIPAA compliance.
- Pricing: HW.Talent, HW.Team, and HW.Hub engagement models, with hourly, subscription, or outcome-based arrangements depending on scope.
- Healthcare proof: In a Medicare Advantage healthcare technology case study, AI-supported member intake reduced call time by 40 seconds (23%) and peak staffing requirements from 450 to 390 agents.
- Recognition and ratings: IAOP Global Outsourcing 100; Clutch 4.8/5 (47 reviews), G2 4.9/5 (30 reviews), and Gartner Peer Insights 4.8/5 (5 ratings).
#2 Claritev (formerly MultiPlan)
Claritev combines payment integrity with provider-network relationships and out-of-network repricing. Payers with complex non-network claims can evaluate these services together, but should distinguish savings produced by repricing from those produced by claim audits before comparing proposals.
- Services: Pre-pay code editing, DRG validation, itemized bill review, repricing, post-pay COB, subrogation, and data mining.
- Best for: Commercial plans, TPAs, and self-insured employers with substantial out-of-network exposure.
- Delivery: US-based company.
- Security: Current product-specific certifications not established in reviewed materials.
- Pricing: Percentage of savings or per-covered-employee fees, according to its filings.
- Healthcare proof: Claritev reported approximately $1.8 billion in medical cost savings across more than 300 payment integrity clients.
- Recognition: Recognized as a Leader in Everest Group’s Pre-payment Integrity Solutions PEAK Matrix Assessment.
#3 Codoxo
Codoxo focuses on preventing payment errors before claims are submitted through AI-powered analytics and provider education. Its approach helps health plans identify recurring billing problems and correct them upstream, reducing the need for downstream denials and recovery. The platform also supports fraud investigations and payment integrity audits.
- Services: Provider education, AI-assisted pre-pay analytics, FWA detection, audit workflow, and medical record review.
- Best for: Health plans, PBMs, and government agencies seeking earlier intervention in billing errors and fraud detection.
- Delivery: US-based company; detailed delivery locations not published.
- Security: HITRUST r2 certified.
- Pricing: Not publicly disclosed.
- Healthcare proof: In a Blues health plan case study, Codoxo reported over $20 million in first-year savings, exceeding projections by 25% through AI-powered provider education.
- Recognition: 2026 Fierce AI Innovation Award for Point Zero Payment Integrity.
#4 Cotiviti
Cotiviti covers both preventive review and post-payment recovery, allowing health plans to manage payment accuracy across the claims lifecycle. Its combined approach reduces the need to coordinate separate vendors for pre-pay and post-pay work, making it relevant for large payers managing complex claims and multiple lines of business.
- Services: Claims editing, clinical review, coding validation, COB, data mining, FWA analysis, and recovery audits.
- Best for: Large commercial, Medicare Advantage, Medicaid, and government programs seeking broad payment accuracy coverage.
- Delivery: International workforce including the US, Canada, India, Mexico, and Philippines.
- Security: HITRUST certification previously announced; current certification scope should be confirmed.
- Pricing: Current commercial terms not publicly disclosed; older filings describe savings-based contracts.
- Healthcare proof: In a national health plan case study, Cotiviti reported a 200-fold increase in pre-pay COB savings since program inception, with 99% of identified opportunities resulting in pre-pay savings.
- Recognition: Everest Group 2026 Leader in pre-payment integrity; KLAS pre-payment score of 82.9 and post-payment score of 82.2.
#5 EXL Service
EXL combines payment integrity analytics with specialist teams that review claims and act on identified errors. Its integrated delivery model helps health plans manage both technology-driven detection and operational execution, reducing the need to coordinate separate analytics and review providers.
- Services: Pre-pay flagging, coding and clinical review, post-pay recovery analysis, COB, third-party liability, and appeals support.
- Best for: Large health plans seeking payment integrity analytics and specialist operations under one partner.
- Delivery: Operations across 11 countries, including the US, India, and Philippines.
- Security: HITRUST certification for relevant healthcare systems.
- Pricing: Outcome-based options; no publicly disclosed rates.
- Healthcare proof: In a health plan payment integrity case study, EXL reported $17 million in recoveries and more than $60 million in identified overpayments during the first full year of the program.
- Recognition: Everest Group 2025 Leader and Star Performer in Payment Integrity Solutions; KLAS post-payment accuracy and integrity score of 83.1.
#6 Gainwell Technologies
Gainwell Technologies
Gainwell specializes in Medicaid administration and program integrity, combining claims technology with fraud detection, clinical review, and third-party liability services. Its experience with state Medicaid systems makes it particularly relevant for government programs that need payment integrity capabilities integrated with existing claims infrastructure.
- Services: Medicaid systems, FWA investigations, clinical claims review, pharmacy audits, post-payment analytics, and third-party liability.
- Best for: State Medicaid agencies, CHIP programs, and Medicaid managed care organizations.
- Delivery: US-centered Medicaid operations; full geographic breakdown not publicly disclosed.
- Security: Product-specific certifications not publicly confirmed.
- Pricing: Not publicly disclosed.
- Healthcare proof: Gainwell reports more than $11 billion in annual savings and recoveries across its payment integrity and fraud, waste, and abuse prevention solutions.
- Recognition: Recognized as a Leader in Everest Group’s Payment Integrity Solutions PEAK Matrix Assessment in 2024.
#7 HealthEdge
HealthEdge applies payment accuracy rules within its broader claims administration technology. Its integrated approach allows health plans to automate pricing and editing before payment while reducing manual intervention. It is particularly relevant for payers modernizing their adjudication systems or seeking tighter integration between claims processing and payment integrity.
- Services: Core administration, claims adjudication, pre-pay payment policy and editing, and business process services.
- Best for: Health plans seeking payment integrity integrated with core administration workflows.
- Delivery: US and India.
- Security: HITRUST, SOC 1 Type 2, SOC 2 Type 2.
- Pricing: SaaS subscriptions; selected managed operations priced per member per month.
- Healthcare proof: In a large Southeast health plan case study, HealthEdge reported six-figure annual savings, a 40% reduction in claims requiring rekeying, and 25% time savings through automated pricing and editing.
- Recognition: 2026 Best in KLAS for Pre-Payment Accuracy & Integrity, with an overall score of 88.2.
#8 Machinify (includes Performant)
Machinify combines AI-powered payment integrity technology with clinical audits, recovery, and coordination of benefits services. Its integrated approach helps health plans manage payment error detection and recovery within one provider relationship, reducing coordination between separate technology and audit vendors.
- Services: Pre-pay editing, payment review, COB, subrogation, clinical and coding audits, and Medicare recovery audits.
- Best for: Commercial and government health plans seeking integrated payment integrity review and recovery.
- Delivery: US operations and broader group resources; combined delivery footprint not fully disclosed.
- Security: Legacy Performant certifications include HITRUST and SOC 1 Type II.
- Pricing: Contingency fees for recovery under legacy Performant contracts; other commercial terms not publicly disclosed.
- Healthcare proof: In a Medicaid health plan case study, Machinify reported recovering $6 million in overpayments within four months by re-reviewing previously cleared claims, with a 99% audit sustainability rate.
- Recognition: Recognized as a Leader in Everest Group’s Payment Integrity Solutions PEAK Matrix Assessment in 2025.
#9 Optum (Change Healthcare)
Optum
Optum combines payment integrity software with clinical review, fraud detection, and recovery services across the claims lifecycle. Its integrated portfolio allows health plans to manage multiple payment accuracy functions through one provider. As part of UnitedHealth Group, Optum also requires buyers to consider data governance and vendor independence when evaluating its services.
- Services: Cost avoidance, claims pricing and editing, FWA detection, clinical review, third-party liability, and post-pay recovery.
- Best for: Health plans seeking integrated pre-payment and post-payment integrity solutions.
- Delivery: US and global operations; payment integrity-specific delivery locations not publicly detailed.
- Security: Product-specific certifications not publicly confirmed.
- Pricing: Not publicly disclosed.
- Healthcare proof: In a pharmacy fraud, waste, and abuse case study, Optum reported more than $128,000 in savings and recoveries over one year for a plan sponsor covering 8,800 lives.
- Recognition: Recognized as a Leader in Everest Group’s Pre-payment Integrity Solutions PEAK Matrix Assessment 2026. KLAS pre-payment score of 79.4 and post-payment score of 57.4.
#4 Zelis
Zelis
Zelis combines claims editing, out-of-network pricing, clinical review, and provider payments within an integrated platform. This approach helps health plans coordinate payment accuracy and reimbursement while reducing fragmentation across vendors. It is particularly relevant for payers seeking to improve savings without increasing provider disputes.
- Services: Claims editing, out-of-network pricing, itemized bill review, clinical claims review, and provider payments.
- Best for: National and regional health plans, TPAs, and self-insured employers seeking integrated pricing and payment integrity.
- Delivery: US and India.
- Security: Product-specific certifications not publicly confirmed.
- Pricing: Contingency-based pricing for pre-payment services, according to Everest Group.
- Healthcare proof: In a regional health plan case study, Zelis reported increasing out-of-network pricing savings from $11.5 million to $21.4 million (86%) while keeping provider dispute turnover below 4%.
- Recognition: Recognized as a Leader in Everest Group’s Pre-payment Integrity Solutions PEAK Matrix Assessment.
Healthcare Payment Integrity Pricing Models
Payment integrity pricing varies by what a vendor delivers and when a benefit becomes real. The most common approaches are:
- Contingency or share of savings: The vendor earns a percentage of prevented or recovered overpayments. Define whether a saving is recognized when flagged, adjusted, collected, or finally upheld after appeal. Claritev reports savings-based contracts; legacy Performant recovery contracts use contingent fees.
- Software fees: Claims editors and analytics platforms can use subscriptions, licensing, transaction volume, or member-based charges. Ask separately about implementation, integrations, support, and additional modules.
- Managed operations: Teams may be priced per agent, FTE, hour, subscription, or outcome. Helpware offers healthcare BPO services through several pricing models; the scope of work and service levels determine a comparable quote.
Request a year-one and year-three cost model. Include internal staff who remain involved, clinical review costs, appeals, data transfers, minimum fees, and transition or termination expenses. For contingency arrangements, agree on claim-line-level savings attribution so two vendors cannot charge for the same correction. Require refunds or adjustments when savings are overturned and specify who bears provider appeal costs.
How to Choose a Healthcare Payment Integrity Company
Start with your own claim data. Identify whether problems arise before payment, after payment, or because staff cannot resolve existing findings. Then use the same claim sample and definitions when evaluating shortlisted vendors.
- Payer and claim fit. Ask for experience with your products, state rules, network structure, and claim categories. Medicare Advantage, Medicaid, commercial, and TPA workflows require different expertise.
- Net results, not headline savings. Request dated results, baseline volumes, recovery time frames, fee treatment, and validated savings after appeals. Vendor-reported identified errors do not automatically become cash recoveries.
- Integration and accountability. Establish whether the provider supplies software, clinical judgment, recovery specialists, or staff working in your systems. Confirm who owns pended claims and provider communications.
- Security and controls. Request current security evidence for the specific product, delivery location, and subcontractors. Confirm protected health information access, audit trails, and breach-notification obligations.
- Provider relationships and transitions. Review turnaround targets, dispute processes, provider communications, and how work continues during implementation or a vendor change.
| Performance measure | Evidence to request |
|---|---|
| Net realized savings | Savings after fees, reversals, and recovery costs |
| Appeal overturn rate | Percentage of findings reversed, by claim type and vendor |
| False-positive rate | Unnecessary reviews and avoidable provider contacts |
| Pre-pay turnaround | Time added to adjudication for correctly paid claims |
| Cost per reviewed claim | Vendor and retained internal effort for comparable work |
Ask for sample dashboards and reference calls from plans similar to yours. When several vendors touch a claim, keep a shared claim-line log of edits, findings, actions, recoveries, and ownership. For operational bottlenecks, healthcare back-office teams can work with existing technology rather than replace it.
Build Your Payment Integrity Program on What Actually Holds It Together
Healthcare payment integrity is not a technology-only problem. It never was. The companies that consistently recover the most savings and maintain the lowest error rates combine strong analytics with strong operational execution. The vendors on this list each address different parts of that equation, from pre-claim AI prevention to government RAC audit programs to core administration integration. No single vendor covers every dimension well. The right answer for most health plans is a deliberate architecture: a primary analytics or platform vendor paired with an operational execution partner whose compliance infrastructure, attrition rate, and institutional knowledge match the standards your program demands. Start with what your current program actually lacks before evaluating what each vendor sells.
