Rated fully compliant. Significant waste still on the table.
A mid-size third-party administrator ran a single ArqAI Blind Spot Assessment over claims its payment-integrity vendor had already cleared. The assessment surfaced significant undetected waste, and sharply cut the team's manual review time while doing it.
What one assessment produced.
Undetected waste
Fraud, waste, abuse, and claims-leakage signals across historical claims the incumbent tooling had already cleared.
Manual review time
The claims team spent far less time on manual review, because flagged cases arrived with the evidence already assembled.
Assessment engagement
The findings came from a single Blind Spot Assessment, not a multi-year platform rollout.
“Fully compliant” is not the same as “nothing left to find.”
The TPA's incumbent payment-integrity vendor had rated the operation fully compliant. On paper, the program was working.
That rating reflected what the incumbent tooling was designed to look for: individual claims scored against generic payer rules. What it could not see was the pattern-level picture: billing behavior that only looks anomalous when you correlate it across providers, members, and time. That gap between “passed the rules” and “nothing left to find” is exactly what a Blind Spot Assessment exists to measure.
- Client: mid-size third-party administrator (anonymized)
- Prior state: rated fully compliant by the incumbent payment-integrity vendor
- Scope: one ArqAI Blind Spot Assessment over historical claims data
- Engine: ArqFWA cross-signal analysis and explainable case scoring
- Findings: significant undetected waste and claims leakage
- Side effect: a sharp reduction in manual claims-review time
What a Blind Spot Assessment actually does.
No rip-and-replace, no long deployment. The assessment reads the data the operation already has and reports what the current program cannot see.
Ingest what already exists
The assessment runs on historical claims, provider, policy, and member data the TPA already has, with no new pipelines, no system migration, and no disruption to live operations.
Correlate signals rule engines score in isolation
ArqFWA reads billing patterns, provider behavior, and member history as one risk picture. Cases that look clean to isolated rule hits become visible when the signals are read together.
Score against a payer-specific pattern library
The analysis draws on a library of 120+ TPA-specific fraud, waste, and abuse patterns, the operating patterns of payer work that generic tools were never designed to look for.
Deliver findings a reviewer can defend
Every flagged case carries the evidence, peer comparisons, and policy references an investigator needs to act, with no black-box scores and nothing the team has to take on faith.
Why review time fell while findings went up.
Traditional payment-integrity tooling produces thousands of isolated rule hits, and the claims team pays for every false positive with review hours. The assessment inverted that: instead of more alerts, the team received fewer, better cases, each one already carrying the evidence, peer comparisons, and policy references a reviewer needs to make a defensible decision. Less time hunting for context, more time acting on cases that matter. That is where the sharp reduction in manual review time came from.
ArqFWA
The payment-integrity accelerator behind the assessment: cross-signal anomaly detection, explainable case scoring, and provider risk profiling for payer operations.
Explore ArqFWAWhat would an assessment find in your claims data?
If your payment-integrity program has been running on the same rules for years, the honest answer is: nobody knows yet. A Blind Spot Assessment is the fastest way to find out.