Healthcare Payer

Running a health plan means millions of claims and prior authorizations. See where AI can help.

Opus builds a live model of how your claims, authorizations and member operations really run: your Digital Twin, mapped live with your clinical and claims teams. Then it puts AI to work, with a person on every decision that affects a member.

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Use cases

How healthcare payer teams use Opus

Some examples of the high-volume workflows teams hand to Opus, across claims, medical management and member operations.

Prior authorization

TodayEvery authorization checked against criteria by hand.

OpusChecks the request against criteria, auto-approves the clear cases, and escalates the rest with an audit trail.

Claims adjudication

TodayClaims checked and coded by hand, exceptions piling up.

OpusAuto-adjudicates clean claims, flags anomalies, routes exceptions with reason codes.

Fraud, waste & abuse

TodaySuspicious billing caught late, if at all.

OpusScreens billing against peer norms, flags upcoding and duplicates, hands investigators a ready case brief.

Appeals & grievances

TodayAppeals triaged and drafted by hand.

OpusClassifies each appeal, pulls the evidence, drafts a resolution letter, a reviewer signs off.

Eligibility & enrollment

TodayApplications validated field by field.

OpusExtracts documents, validates completeness, pre-populates enrollment, routes exceptions.

Care-gap identification

TodayGaps spotted late, from scattered data.

OpusSpots open quality gaps, generates member outreach, tracks closure for reporting.

The problem

You know AI can cut admin cost and prior-auth delays. Where it actually helps isn't clear.

Every payer has seen the numbers. AI could save the industry billions. What none of them can see is where that value sits in their own operation: which workflows are worth changing, what a change is worth to their medical loss ratio and admin cost, or whether it'll move the bottom line at all. That's the gap Opus closes.

How it works

How it works differently

See the work as it really runs, and know the value of a change before you make it.

01 · Digital Twin
A living model of how your operation actually runs

A living model of how your claims, prior-auth and member operations actually run today, and how they change as you improve them. Because the work runs on Opus, the Digital Twin stays current, so you can see what a change is worth before you make it, and what it adds up to across the plan.
02 · Discover
How the Digital Twin gets built

Mapped live with your clinical and claims teams, the people who do the work, not guessed from system logs. In place of months of manual process mapping, you get the real cost of the work today.
03 · Build, run, optimise
Most tools just automate your process exactly as it runs today

Opus redesigns it for AI first, then runs the better version, so you're improving the work, not just speeding up a flawed one. A person stays on every decision that affects a member, and it keeps learning after go-live.