The short version 

Most medical bills get paid as a discount off whatever the provider charged. If the charge is inflated or wrong, the payment is too. WellRithms changes the starting point. We look at what care was actually delivered, figure out what it is reasonably worth, and give the payor a payment amount with the reasoning to back it up. 

That is payment integrity. Every payment should be correct, fair, and defensible. 

The problem we solve 

Hospitals and providers set their own prices. The same procedure can be billed at wildly different amounts depending on the facility, and billed charges often have little connection to what the care costs to deliver. 

On top of that, bills carry errors. Codes that don’t match the records. Duplicate lines. Supplies and implants priced far above cost. Charges for services that were never documented. 

The traditional fix is a network discount. But a discount off an inflated or inaccurate bill is still an inflated or inaccurate payment. The discount hides the problem. It doesn’t fix it. 

What WellRithms does 

WellRithms runs one payment integrity engine that combines AI-driven analysis, validated pricing data, and physician review. It answers the same question on every bill: what should actually be paid here, and can we prove it? 

Depending on the situation, the engine does one of two jobs: 

 Either way, the payor walks away with a number and the documented logic behind it. 

The life of a bill 

Here’s what happens from the moment care is delivered to the moment a payment is settled. 

 The payor doesn’t have to argue the bill. The patient doesn’t get dragged into it. And on qualifying claims, Shield indemnification means the payor isn’t carrying the risk alone. 

Discount vs. defensible 

Proof that it holds up 

Anyone can cut a bill. The real test is whether the payment sticks. In one health plan program reviewed over seven months: 

 Low appeals and minimal additional allowed are the signals that matter. They show the reasoning held up with the providers who received the payments. 

Who benefits 

Payment integrity works best when it works for everyone touching the bill. 

• Payors  get accurate, consistent payments, clear visibility into what they’re paying for and why, and less exposure to waste and markups. 

• Patients  stay out of billing disputes and keep access to the providers they choose. 

• Providers  get paid fairly for the care they delivered, with clear reasoning instead of an unexplained cut. 

• Brokers, consultants, and TPAs  get a way to show clients real cost control without asking them to rebuild their plan. 

Who it’s for, and how to start 

WellRithms is built for organizations that carry real financial responsibility for medical bills and want more control over what they pay. That includes self-funded employers, union trusts, health shares, and the TPAs, brokers, and consultants who serve them. In Workers’ Compensation, Comp42 brings the same engine to carriers and claims administrators handling high-severity bills. 

There’s no plan redesign and no new network. Most payors start small, with one bill, one case, or one claim type, see the results, and expand from there. WellRithms fits into the workflows you already have. 

What to look for in a payment integrity partner 

Not every review is equal. Before you choose a partner, ask: 

• Do they review every line? Summary-level pricing misses the errors that drive overpayment. 

• Are physicians involved? Clinical decisions should be made by clinical experts. 

• Can they explain every payment? If the reasoning can’t be shown to a provider, it won’t hold up. 

• Who handles the pushback? A strong partner deals with providers directly and stands behind its numbers, including indemnification where it applies. 

• Will you see the results? Look for clear reporting on savings, appeals, and additional allowed, not just a savings total. 

Common questions 

Isn’t this just a way to pay providers less? 

Short answer: No. It’s a way to pay them correctly. 

The goal isn’t the lowest number. It’s the right one, based on what was documented, coded, and delivered, measured against validated pricing data. Sometimes that confirms the bill. Often it removes errors and markups. Either way, the reasoning is on paper, which is why so few payments come back as additional allowed. 

Will patients end up with balance bills? 

Short answer: They can happen under any plan, but they’re far less likely when providers understand the payment. 

A balance bill happens when a provider bills the patient for the difference between their charge and what was paid. When every payment comes with clear reasoning and WellRithms answers provider questions directly, most issues get resolved before they ever reach the patient. Shield adds another layer of protection on qualifying claims. 

Don’t providers fight these reviews? 

Short answer: Providers fight reductions they can’t understand. 

Most pushback comes from unexplained cuts and legacy pricing habits, not from fair review. When a provider can see exactly how a payment was determined, there’s much less to argue about. That’s reflected in a 0.3% appeal rate across more than 27,000 claims. 

Do we have to change our network, TPA, or plan? 

Short answer: No. 

WellRithms works inside the structure you already have. We review in-network claims beyond the network discount and price out-of-network and single-case bills defensibly, all through your existing workflows. Patients keep their providers. You keep your partners. 

The bottom line 

WellRithms gives payors confidence in every payment decision. The bill is accurate, the payment is fair, and the reasoning holds up.