Payment integrity for self-funded employers
Up to 15% of your medical claims are paid wrong.
Klaims.ai reviews every claim against your plan document, flags what shouldn't have been paid, and recovers it for the plan and for your members. Your data stays yours, whoever administers it.
Why this matters now
Health benefits are a fiduciary responsibility now, not just a line item.
Healthcare is the second-largest expense on most profit and loss statements, and the one the C-suite has been told is uncontrollable. It isn't. It's unexamined.
Since the Consolidated Appropriations Act, plan sponsors are expected to know what they're paying for and to be able to show they checked. Suits like the one filed against Johnson & Johnson made the exposure concrete: a plan sponsor who never reviewed their own claims has no answer when asked what diligence they performed.
Meanwhile employees absorb the difference through deductibles, co-pays and contribution rates, and overpayments on their claims come out of their pockets too.
The platform
Four parts. One claims file.
Start anywhere. Most plans start with a look-back review because it pays for itself, then turn on prepayment so it stops happening.
Own the data your vendors hold
We onboard, warehouse and secure your claims feeds so you have one access point, and so changing a TPA or carrier never means losing your history.
- We build and maintain the data connections
- Cleansed, enriched and normalized on arrival
- Portable. The file leaves with you
See where the spend actually goes
Automated reporting and dashboards that surface trends, cost drivers and point-solution performance without waiting on a vendor's quarterly deck.
- Shareable reporting for finance and HR
- Model plan design changes before you commit
- Track whether point solutions earn their fee
Get back what was paid in error
We review 100% of medical claims, typically three years back, against your plan document and contract terms, then pursue what was overpaid.
- Duplicates, unbundling, modifier misuse, repricing errors
- Recovery pursued on the plan's behalf
- Member cost-share corrected too
Stop paying them in the first place
The same review logic runs before funds are released, so questionable lines get resolved while you still have leverage rather than chased afterward.
- 100% of claims screened pre-payment
- No disruption to member experience
- Turns recovery into prevention
How recovery works
Four steps, and you only pay from what we find.
Get the claims file
We work with you and your TPA to obtain the medical claims file, a standard claims extract. We handle the request and the intake.
Review every line
All claims are tested against your plan document, contract rates and coding rules. Not a sample.
Flag and document
Each exception comes with the reason, the source language and the dollar amount, ready for review.
Recover the funds
We pursue validated overpayments and return them to the plan and to affected members.
Estimate
What might be sitting in your claims file?
Enter your plan's numbers for a directional estimate. Move the assumption slider to see how sensitive the result is.
Auto-filled at $12,000 per employee per year, a blended working benchmark informed by the KFF Employer Health Benefits Survey (2025 averages: $9,325 single coverage, $26,993 family coverage). Type over it with your plan's actual spend.
Reviews commonly find that up to 15% of claims contain an error. The slider runs from a conservative 3% to that 15% ceiling. Start low and move it up to see how sensitive the result is.
Three-year look-back
Ongoing, each year
Directional estimate only, based on the assumption above and an 80/20 plan-member split. Your actual figure comes from reviewing your claims file. That review is where the real number appears.
Start here
Send us a claims file. We'll tell you what's in it.
A discovery call takes about 30 minutes. Bring your current TPA arrangement and last year's spend, and we'll walk through what a review would look for and what it typically returns.