Payer Performance Studio
Reducing Medical Spend.
Streamlining Operations.
Protecting Relationships.
HealthWorks Welcomes Forensic Claims Solutions
Driving Precision Through Forensic Technology
With the integration of Forensic Claims Solutions, HealthWorks expands the Payer Performance Studio with the innovative Sleuth© platform and a library of advanced data mining algorithms. Together, these capabilities deliver predictive insights, smarter audits, and stronger compliance—helping payers reduce medical spend, prevent inappropriate payments, and operate with greater confidence.
Ensuring Payment Accuracy
We Sit at the Center to Make Heathcare Work Better for Everyone.
At HealthWorks, we sit at the intersection of payers and providers, helping both sides achieve what matters most: accuracy, efficiency, and trust.
For too long, misaligned incentives and administrative burden have created friction in the system. We change that by aligning payers and providers around clarity and compliance—making healthcare work better for everyone.
When Payers and Providers Align, Everyone Wins.
For Payers…
Cleaner claims, fewer disputes, stronger compliance, reduced waste
For Providers…
Faster, accurate payments with less abrasion and administrative burden
For Healthcare Overall…
A system that runs with greater efficiency, integrity, and collaboration—lower costs and improving outcomes
Our Solutions
Smarter Tools to Reduce Spend and Strengthen Accuracy
The HealthWorks Payer Performance Studio delivers a suite of services designed to build accuracy into the payment process, reduce waste, and minimize friction with providers. Each offering is backed by operational leaders with deep payer, provider, and CMS experience.
Medical Records Review
Ensure Fair, Defensible Payments With Clinical-Level Validation
Clinical-level reviews of inpatient claims ensure DRG assignments are accurate, defensible, and compliant—strengthening audit readiness and supporting fair payment.
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Prevent costly inaccuracies with expert DRG and coding reviews.
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Strengthen audit readiness and reduce compliance exposure.
Data Mining
Surface Actionable Insights to Reduce Waste and Optimize Spend
AI-powered analysis identifies patterns, anomalies, and inefficiencies in claims data—turning complexity into actionable intelligence that reduces waste and guides resources where they matter most.
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Identify patterns, anomalies, and inefficiencies across claims data.
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Focus resources on the highest-impact opportunities to reduce spend.
Member Monitoring Subrogation
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Identify Third-Party Liability Claims That Aren’t Yours to Pay
Continuous monitoring of member data to flag potential third-party liability, with automated triggers and expert recovery that convert missed opportunities into recovered dollars.
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Leverage extensive, proprietary, defensible data to accurately identify the responsible party.
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Avoid mispayments and reduce financial leakage with real-time monitoring and expert validation.
Provider Retraction & Collection
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Recover Overpayments While Preserving Provider Trust
A compliant, provider-sensitive recovery program that minimizes abrasion while maximizing resolution, with full-service outreach and processing management.
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Compliant, provider-sensitive outreach minimizes abrasion.
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Full-service tracking and management accelerate resolution.
Credit Balance Automation
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Resolve Credit Balances Faster and Strengthen Compliance
Technology-driven workflows that eliminate manual reconciliations, accelerate credit balance resolution, and ensure compliance with audit-ready documentation.
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Automated reconciliation eliminates manual effort and delays.
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Clean, documented workflows improve compliance and audit readiness.
Electronic Communication
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Cut Administrative Costs With Digital-First Communication
Secure digital communication established during enrollment to reduce costs, prevent overpayments, and improve collaboration among payers, providers, and patients.
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Secure, digital pathways reduce paper, costs, and delays.
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Improve provider and member engagement to prevent disputes and overpayments.
The Impact
Precision-Driven Payments, Delivered Faster
HealthWorks helps payers streamline operations, reduce friction, and ensure accurate payments the first time. By embedding intelligent validation, documentation alignment, and collaborative communication tools into the claims lifecycle, we enable faster resolution, fewer disputes, and better outcomes for all stakeholders.
A Better Payment System for All:
For Payers:
Streamlined workflows, fewer disputes, and improved claim payment integrity.
For Providers:
More accurate payments, reduced rework, and faster reimbursement.
For Patients:
Clearer bills, fewer delays, and a more trustworthy financial experience.
The Benefits
The Measurable Impact of Process Integrity
At HealthWorks, we measure success by the impact it has on your bottom line and the strength of your provider relationships.
Our Payer Performance Studio is designed to reduce unnecessary spend, lower administrative burden, and build accuracy into the process—so you can focus on strategy, not rework.
By combining advanced analytics, proprietary data, and decades of operational experience, we help payers pay the right claim, the first time. The result is not only financial savings, but also a stronger foundation of trust with providers and members alike.
Reducing Spend, Lowering Costs, Strengthening Trust
Partnering with HealthWorks delivers measurable benefits that directly impact spend, compliance, and operational efficiency.
- Reduced Medical Spend through accurate claims, fair DRG validation, and subrogation recoveries.
- Lower Administrative Operating Costs by automating reconciliations, reducing manual reviews, and minimizing disputes.
- Improved Compliance & Audit Readiness with defensible, documented processes.
- Stronger Provider Relationships by reducing abrasion and enabling clear, consistent communication.
- Operational Efficiency from actionable intelligence and seamless integration into existing technology stacks.
Our Senior Leadership Team
Led by the Pioneers of Modern Payment Integrity
HealthWorks is led by seasoned operators who helped pioneer modern payment integrity—bringing proven expertise from payers, providers, and CMS.
Darby Brown
A nationally recognized leader in healthcare payment innovation, Darby has built and scaled some of the industry’s most respected payment integrity programs.
Harold Davis
President
With more than three decades at Humana, Harold directed cost containment operations spanning FWA, subrogation, and code edits—leading a program recognized as world-class.
Chad Heflin
Executive Vice President
Chad leads strategic payer initiatives, with deep expertise in subrogation, coordination of benefits, and recovery services that reduce costs while preserving provider trust.
Michael McGauley
With 25+ years in payer operations and payment integrity, Michael co-founded Forensic Claims Solutions and built audit and recovery programs that improved compliance, reduced spend, and delivered results for health plans.
Craig Mills
EVP | Data Mining Technology
With 20+ years in healthcare tech, Craig co-founded Forensic Claims Solutions and developed the Sleuth© platform and algorithms that give payers predictive insights to strengthen accuracy and prevent mispayments.
Let’s Improve Payment Precision—Together.
Partner with HealthWorks to reduce medical spend, strengthen compliance, and protect relationships—without adding complexity.