There is a peculiar moment in American healthcare when a medical claim becomes a payment. A provider has chosen the codes. A network has applied a price. A third-party administrator has adjudicated the file. For a self-funded employer, the money about to leave is not an insurer's money. It belongs to the employer's health plan. Yet the person signing off may see only a polished dashboard and a total, the financial equivalent of approving a restaurant tab without reading the items.
ClaimInformatics, a 23-person company in Bloomfield, Connecticut, has built its business around that awkward handoff. It receives claim data, runs the transactions through evidence-based and proprietary edits, and points to duplicate payments, unbundled procedures, invalid codes, questionable medical necessity and other inconsistencies. It can work after payment, when recovery begins, or before payment, when the incorrect check never has to be written.
The software is called ClaimIntelligence. The larger idea is less technical: do not let the organization that prices or processes the claim be its only referee. ClaimInformatics says it has no carrier ownership, provider contracts or network relationships. In a benefits market woven from rebates, commissions, shared savings and opaque service agreements, independence is the thing it is actually selling.
The audit that moved upstream
CEO and co-founder Stephen Carrabba did not arrive through medicine. After college, he started companies in contingency-based cost reduction and built technology to audit pharmaceutical claims for hospitals and nursing homes. Medical claims were a nastier puzzle. Pharmacy audits can orbit a relatively small vocabulary of drug codes and prices. Medical billing stacks CPT, HCPCS, DRG and diagnosis logic with eligibility rules, facility settings, clinical evidence and contract language. The acronyms multiply faster than the answers.
Carrabba has said a co-founder's suggestion moved the work from pharmacy to medical claims. He, claims veteran Dawn Cornelis and engineer Steven Shepherd founded ClaimInformatics in 2017, initially reviewing old payments. Cornelis brought decades inside claim processing and plan administration. The early service was forensic: obtain the data, re-adjudicate the claims, show the employer what should not have been paid, then pursue the money.
What failed first was not the audit. It was timing. Once cash reaches a provider, a correct finding becomes a collection project, and recovery gets harder with every passing month. A plan can have flawless evidence and still face appeals, provider friction, member confusion or a client unwilling to pursue the full amount. The team's answer was to put the same logic before the check.
In public interviews, the company describes returning corrected files within roughly 12 hours. One example has a $30,000 incorrect claim stopped by a review costing $4. Treat the four-dollar figure as an illustration, not a universal quote. The more durable point is operational: a small, fixed checkpoint can sit in front of a large and difficult-to-reverse transaction.
“Most plan sponsors are looking at the summary, not the claims.”Stephen Carrabba, co-founder and CEO
Two engines, one paper trail
ClaimIntelligence handles payment integrity. It tests every submitted claim rather than sampling and spans 15 broad edit categories, from deleted codes and drug billing to inpatient pricing and the company's Episode of Care logic. Pre-pay review prevents questioned payments; post-pay review finds them later. PAIR, the Plan Accountability and Integrity Review, looks back across roughly one to three years. Ongoing Monitoring repeats the exercise monthly and surfaces provider patterns, costly procedures and recoveries in a dashboard.
FOCUS adds the governance layer. Its name expands to Fiduciary Oversight, Compliance and Utilization Safeguard, which is perhaps proof that healthcare can turn even a verb into an acronym. The useful distinction is that FOCUS does not merely count suspicious dollars. It organizes the evidence that a plan sponsor monitored vendors, followed plan documents, checked fees and acted prudently.
CLEAR sits inside that work. The Contract Language ERISA Analysis and Redline service reviews ASO and TPA agreements, Summary Plan Descriptions, pharmacy-benefit contracts and stop-loss documents. ClaimInformatics says it applies more than 1,100 checks against ERISA, the Consolidated Appropriations Act, mental-health parity law and related requirements, then supplies risk ratings, citations and proposed redlines for legal counsel.
Where the company looks
Bars show breadth of workflow, not measured market share or performance.
The AI story is refreshingly unmagical. Carrabba says an early generic approach to contract analysis was poor. The working system took about eight months, a curated knowledge base of roughly 15,000 pages, specific questions applied to contract language and guardrails around the output. Generative tools now help spot patterns, speed creation of new edits and explain logic in plain English. The domain rules and human review remain the product's spine.
The referee should not bet on the score
Payment-integrity firms have traditionally taken a percentage of what they identify or recover. The arrangement seems painless: the customer pays only when the vendor finds money. It can also create a quiet contradiction. If fixing a root cause makes the same error disappear next month, the vendor's future fee shrinks. A plan may pay repeatedly for the discovery of a mistake that should have been eliminated.
In July 2026, ClaimInformatics announced that pre-pay review would carry a flat fee for every claim, regardless of whether the claim passed or failed. No dollar threshold, no percentage of the denial and no per-employee-per-month fee for that service. Historical recovery can still use success-based pricing, and the platform can be licensed to brokers, auditors and consultants. The company does not publish a complete rate card.
That distinction is its sharpest competitive wedge against bundled carrier programs, internal review teams and large payment-integrity vendors. ClaimInformatics is paid to inspect, not to maximize the apparent score. The model is also legible to an ERISA fiduciary who must judge whether compensation is reasonable. A flat unit price is easier to explain than a fee that rises with disputed savings.
Scale matters, but most results remain company-reported. ClaimInformatics said it analyzed more than $2 billion in claims over the six months preceding April 2026 and flagged 8.7 percent. On the Broken Healthcare podcast, Carrabba described one engagement that identified $7.4 million in questioned payments in 60 days, a 10.9 percent rate. Those numbers are signals, not guarantees. Plan mix, contract language, data quality and prior controls can produce very different results.
Why the law changed the sales conversation
The company was early to a market that did not always want to look. Carrabba says demand shifted materially after the Consolidated Appropriations Act of 2021 strengthened expectations around data access, compensation disclosure and health-plan fiduciary duties. Over the following years, lawsuits against plan sponsors and scrutiny of service-provider fees made “show me the process” more than a procurement preference.
This changed ClaimInformatics' center of gravity. It remained a cost-containment company, but its buyer could now justify the work as governance. The customer set broadened to CFOs, HR leaders, benefits committees, captive programs, Taft-Hartley funds, independent TPAs and the consultants advising them. The Detego Health partnership, in production since September 2025, is a neat example: Detego administers the plan while ClaimInformatics independently reviews claims before payment.
The business has been financed modestly by health-tech standards. SEC filings show $2.25 million sold in a 2022 debt offering and another $1.5 million in 2024. No valuation is public. LinkedIn lists 11 to 50 employees and showed 23 employee profiles in 2026. In April, the company said operational changes led by incoming COO Michael Riemer cut nearly $1 million in annual costs and helped produce three cash-flow-positive quarters. That announcement came from ClaimInformatics itself, but it sketches a company learning to sell discipline while applying some internally.
What a buyer can steal
The most copyable part of ClaimInformatics is not a proprietary claims edit. It is the architecture of accountability. Put an independent check between a powerful operator and an irreversible payment. Give that checker raw data rather than a curated summary. Charge for the inspection instead of the drama of the result. Then save the rationale in a form another person can audit.
The five-step plan-sponsor copybook
- Ask for complete claim-level data in a usable format, not only carrier dashboards.
- Review ASO, plan, PBM and stop-loss language before renewal, when leverage is highest.
- Move controls pre-pay where the workflow and administrator allow it.
- Price oversight so the reviewer does not benefit when the same failure repeats.
- Track the finding, action, owner and result to create a defensible record.
There are conditions where the playbook stalls. If the contract blocks outside audits, the employer cannot retrieve complete claims data, or the TPA cannot accept a corrected file on time, pre-pay review becomes a diagram rather than a control. A fully insured employer may not own the claim risk or data at all. A very small plan may not produce enough volume to justify integration. And software cannot force a fiduciary to pursue recoveries, renegotiate a contract or challenge a valued provider.
Nor is independence a substitute for validation. Buyers should test findings, inspect false positives, define appeal rules, review security controls and measure actual cash retained or recovered. “We found savings” is precisely the kind of summary ClaimInformatics tells employers not to accept from anyone else.
Still, the company has located an honest little absurdity at the center of a giant industry: the party writing the check often has less information than everyone sending the bill. ClaimInformatics does not promise to simplify American healthcare. It proposes something narrower and more believable. Read every line before the money leaves, and keep the receipt for the decision.
Keep digging
Explore the company, its public commentary and two long-form conversations about the mechanics behind the pitch.