The WellRithms Solution

WellRithms’ review and repricing system ensures accuracy and fairness before payment.

In-Network Impact

Network discounts alone do not ensure accuracy. Medical bills and claims can still contain errors that result in overpayment even when processed through established PPO agreements. WellRithms applies line-by-line review to uncover billing inaccuracies that network pricing does not address.

Classification, Edits, & Review™ (CER)
The Foundation of Every WellRithms Review

In-network medical bills and claims are reviewed line by line using WellRithms’ Classification, Edits & Review system.

This process focuses on uncovering:

• Classification accuracy: Confirming place of service and provider type are correctly assigned
• Edit compliance: Identifying services that should not be billed separately under national billing standards
• Clinical validation: Ensuring services billed were actually performed and coded correctly

This review complements PPO discounts by addressing errors that discounts alone do not catch, revealing additional accuracy beyond contracted rates.

Inpatient Itemized Bill Review (BRAID™)
Clinical Review Paired With Automation

Inpatient medical bills require a higher level of scrutiny due to their complexity and financial impact. BRAID combines automation with physician-led clinical review to uncover inaccuracies at the itemized level. This approach allows WellRithms to clarify billing support efficiently while maintaining clinical credibility.

Key elements include:

• Physician-led review for clinical accuracy
• Automated analysis for speed and consistency
• Provider profiling to improve future review efficiency
• A continually learning rules engine that improves accuracy over time

The goal is not aggressive repricing, but clear, defensible reimbursement aligned with what the bill supports.

Revealing What Is Fair And Reasonable

Out-of-Network Impact

Out-of-network medical bills often lack clear pricing guardrails, making fairness and accuracy harder to establish. WellRithms applies line-level analysis rooted in reported cost data to clarify what reimbursement is fair and reasonable based on the services provided.

Sustainable Claims Pricing™ (SCP)
Line-Level Accuracy That Holds Up

Out-of-network medical bills and claims are reviewed line by line using Sustainable Claims Pricing focuses on uncovering accurate reimbursement at the line level using cost-based data rather than arbitrary percentage reductions.

This approach:

• Applies reported cost data and algorithms to each billed line
• Avoids blanket reductions that fail under scrutiny
• Supports fair, reasonable reimbursement without exaggeration

By grounding decisions in actual cost data, WellRithms helps plans bend spend trajectories while maintaining defensibility.

Air & Ground Ambulance Repricing
Accuracy Where Errors Are Common

Ambulance medical bills frequently include unbundled charges, incorrect mileage, or services not supported by medical necessity.

WellRithms reviews ambulance claims to:

• Confirm pickup and drop-off accuracy
• Identify unbundled or inclusive charges
• Assess medical necessity for transport services

Repricing aligns payment with fair market rates supported by the services rendered, ensuring accuracy before payment is finalized.

Recon & Dispute Impact

Even when medical bills are reviewed carefully, providers may request reconsideration or initiate disputes. WellRithms manages this process end to end, ensuring decisions remain grounded in accuracy and consistency.

WellRithms applies line-level analysis rooted in reported cost data to clarify what reimbursement is fair & reasonable based on the services provided.

Reconsideration & Dispute Management
We Handle The Pushback

From initial reconsideration through dispute resolution, WellRithms manages provider communication and defense so plans do not have to.

This includes:

• Data-supported reconsideration responses
• Medical and billing expert review of each challenge
• Deadline tracking and process management
• Transparent reporting throughout the lifecycle

Our role is not to escalate conflict, but to reinforce accuracy when questions arise.

RBP Clean Up
Resolving What Was Left Unfinished

When Reference Based Pricing disputes remain unresolved, WellRithms steps in to clarify reimbursement accuracy and resolve outstanding issues.

This service focuses on:

• Bringing unresolved disputes to closure
• Ensuring reimbursement reflects defensible rates
• Removing uncertainty for both plans and members

The objective is resolution built on accuracy, not prolonged negotiation.

Shield Indemnification™
Protecting Health Plan Dollars

Shield Indemnification provides protection against financial risk associated with disputed medical bills where accuracy is clearly established. When applicable, Shield Indemnification™ allows plans to transfer financial liability associated with provider disputes to WellRithms, reducing exposure and operational burden.

Shield Indemnification™ is supported by:

• Demonstrated accuracy in specialty bill review
• Established case law and favorable decisions
• Structured processes designed to withstand scrutiny

Shield Indemnification™ is not a blanket guarantee. It is applied carefully, where appropriate, to support fair and accurate outcomes when disputes persist.

How To Work With WellRithms

WellRithms offers flexible engagement options, including single-case reviews, to help organizations evaluate medical bills and claims with clarity. Whether reviewing isolated cases or supporting broader initiatives, our approach remains the same: uncover accuracy, apply standards consistently, and reduce friction through clarity.

Closing Perspective

In Group Health, trust is built when medical billing decisions are fair, accurate, and able to hold up under scrutiny. WellRithms exists to bring that clarity before payment is made, helping plans, providers, and members move forward with confidence.

“In group health, trust us built when medical billing decisions are fair,
accurate, and able to hold up under scrutiny.”