Payer Services
Managing Risk. Ensuring Accuracy. Strengthening Control.
Smart Payer Solutions
We, Talisman Solutions, support payers, insurers, insurance companies, and Third-Party Administrators (TPAs) with structured payer solutions across fraud prevention, payment integrity, utilization management, claims operations, and member data governance.
Our framework combines AI-driven analytics, predictive risk modeling, workflow automation, and secure, audit-ready processing environments — supported by clinical and operational oversight where required.
The objective is clear: reduce financial leakage, improve decision accuracy, and strengthen payer and insurer performance without disrupting existing core systems.
Fraud & Risk Services
Key Focus Areas
Protect revenue before payment is released.
Fraud, Waste & Abuse Prevention
Our Fraud, Waste & Abuse Detection Engine reviews claims pre-payment to identify abnormal billing behavior such as upcoding, unbundling, phantom billing, duplicate submissions, and irregular utilization trends.
The system evaluates provider behavior patterns and cross-claim inconsistencies to surface risk early. It adapts to different reimbursement models and regulatory frameworks, supporting payers, insurers, and TPAs across the United States, the UAE, India, and other structured healthcare markets.
Ensure payment accuracy and contract alignment.
Payment Integrity Oversight
We verify that claims are paid correctly based on contract terms, coding standards, and coverage policies. Structured pre- and post-payment reviews identify pricing discrepancies, duplicate reimbursements, and documentation gaps.
For risk-based programs, we validate HCC coding through medical record review to improve risk score accuracy and support compliance for insurance companies and managed care organizations.
Clinical markers for:
Management of:
Accurate risk score validation.
Risk Adjustment Coding
We review medical records to confirm HCC coding accuracy for Medicare Advantage and value-based programs. This improves risk score precision and reduces compliance exposure for insurers and health plans.
Utilization Management Services
Structured authorization and clinical review.
Automated Prior Authorization
We streamline prior authorization workflows using AI-supported decision logic aligned with coverage policies. Routine requests are evaluated automatically, while complex cases are routed for clinical review — supporting efficient decision-making for payers and insurance administrators.
Consistent coverage determination.
Medical Necessity Review
AI-assisted clinical review supports evaluation of complex claims to determine eligibility and appropriateness of care, ensuring standardized and defensible decisions for insurers, TPAs, and self-funded employer plans.
Operations Services
Operational accuracy before payment.
Claims Adjudication Support
We support eligibility verification, benefit validation, provider status confirmation, and pre-payment logic checks before final payment determination — ensuring operational accuracy for payers and insurance carriers.
Claim Ingestion
Verifying metadata structure...
Network Maintenance
Polling provider endpoints...
Maintain network integrity
Provider Network Management
We assist with provider credentialing oversight, contracting coordination, and directory accuracy to support compliance and network adequacy standards for health plans and insurance organizations.
Member Services
Reliable enrollment data.
Member Eligibility Management
We implement systems that manage enrollment data and ensure real-time coverage validation. Accurate member records reduce claim errors and improve operational efficiency for insurers, TPAs, and managed care entities.