Independent second-pass claim review.
Orchid independently reviews targeted claims against the available medical record and applicable reimbursement requirements, then shows reviewers what warrants attention, why, and the evidence supporting the finding.
Talk through whether a retrospective validation makes sense for your claims environment.
Keep what already works.
The initial question is not whether Orchid can replace your current payment-integrity infrastructure. It is whether an independent evidence-bound review can identify defensible issues your existing process did not.
Orchid adds an independent second pass to your existing claims edits, payment-integrity vendors and internal review processes.
What defensible payment-integrity opportunities are still getting through?
Orchid does not get to see the answer.
Orchid reviews the claim and available medical record against the agreed reimbursement requirements. The outcome is revealed afterward, so the comparison measures what Orchid found — not what it already knew.
- 01
Orchid reviews blind
The claim, the available medical record, and the agreed reimbursement requirements. Not the outcome.
- 02
Orchid produces the finding
With the supporting evidence, the governing requirement, and what it could not settle attached.
- 03
Outcomes are revealed
The actual adjudication result, and what your existing payment-integrity process identified.
- 04
The results are compared
Overlap, incremental findings, reviewer agreement, and disagreements worth examining.
The known outcome is evaluation data. It is never an input Orchid reasons from.
A finding should show its work.
Orchid keeps the claim facts, the applicable requirement, the supporting evidence, conflicting or missing evidence, source citations, and the reason for attention together in one reviewable finding.
- Claim facts
- Applicable reimbursement requirement
- Supporting medical-record evidence
- Conflicting or missing evidence
- Source citations
- Unresolved uncertainty
- The basis for reviewer attention
The reviewer decides what happens next. The health plan remains responsible for any decision to pay, pend, deny, request records, escalate, recover, or take no action.
Orchid does not autonomously adjudicate claims or make payment determinations.
Start where the answer depends on the record, not claim fields alone.
A first validation is scoped to a defined cohort so the comparison is measurable. Where that cohort sits is a choice, not a limit.
- Documentation-dependent coding
- Modifier support
- Procedure support
- Medical-necessity or payment-policy requirements
- Other record-dependent claim questions
A validation may include
- A defined claim cohort
- Historical adjudicated claims, with medical records for a selected subset
- The reimbursement requirements that apply
- Blind Orchid review, before any outcome is shared
- Comparison with actual outcomes and existing payment-integrity results where available
- Evaluation by the health plan's designated reviewers
Potential outputs
- Orchid findings and the evidence behind them
- Overlap with the existing process
- Incremental findings
- Reviewer agreement
- False-positive analysis
- Financial opportunity where calculable
- A recommendation on whether further testing is warranted
Start retrospectively
Orchid reviews a defined cohort of adjudicated claims against the available medical record and applicable reimbursement requirements, then compares its findings with the health plan's existing payment-integrity process.
Measure what Orchid finds, what the current process already caught, reviewer agreement, and the incremental financial opportunity.
Move proven concepts upstream
Concepts that demonstrate value can move into shadow-mode pre-payment review, allowing the health plan to evaluate Orchid's findings before payment without changing adjudication.
From there, validated concepts can support production pre-payment review.
Test Orchid as a second pass.
Talk through whether a retrospective validation makes sense for your claims environment.