Health Plans Need Help. Incrementalism Is the Enemy.

Health plans need help. Now. The legacy of antiquated claims systems, labor-intensive processes, expanding compliance risk, escalating MLRs, and inflated administrative costs is unsustainable.

At a recent healthcare conference in Dallas, executives were asked a question from the podium, “How many of you are processing claims on a platform that is 25-years old or older?” Almost every hand in the room was raised. And that was just one of many questions that could have been asked that are reflective of a common challenge – core operating systems are old and expensive to operate in every dimension imaginable.

Incrementalism and disconnected approaches just won’t work anymore. You need technology-driven financial and operational systems with a flexible, connected core that can seamlessly build on top of each other and easily integrate with other systems. And you need performance guarantees and innovative financial structures that empower you to deliver the change you need now…not years from now.

If you are a health plan, TPA or self-insured senior executive, email Fast@4LData.com to discuss the technical and financial power to break out of incrementalism and into high performance.

Provider Data Accuracy Is Attainable.

Forty-nine percent of provider locations had at least one data error, according to CMS in a Fierce Healthcare publication from 2019. That’s just one data element out of hundreds that was wrong half the time according to CMS.

Another CMS study published in JAMA 2023, indicated that 41.75% of provider locations in directories had inaccuracies that prevented patient access. That same publication indicated that up to 81% of all provider data is inaccurate. That’s a problem that plagues healthcare payers, health systems, and networks every single day. 4L Data has identified seven (7) elements that represent the root cause of chronically inaccurate provider data.

Knowing the root cause of the provider data inaccuracy problem is step one. The next step is defining a good definition of what accuracy is. We define accurate provider data as having five (5) characteristics: 1) continuously monitored and updated every day, 2) independent of provider-provided data, 3) delivers near real-time time alerts on critical data such as addresses and integrity data, 4) provides a robust data set including demographic, directory, integrity, affiliation, integrity, ratings, billing behaviors, and licensure, and 5) functions such as change notices and attestation should be fully automated.

The good news is that this solution already exists with 4L Provider Intelligence™ that features hundreds of data elements continuously monitored and updated with double and tripe channel source verification on 8.9M providers every day.

If you want a copy of the presentation titled, The Accuracy Challenge – A Provider Data Narrative, email us at Fast@4LData.com.

SIUs Can’t Keep Up With Investigations. Help Is Here.

During the 2025 4L Fraud Advisory Council collaboration in Dana Point, CA, SIU leaders, investigators, and payment integrity executives spent two days ideating around key problems that need to be solved in the fight against fraud, waste, and abuse. SIU efficiency was the number one issue the group chose to spent time on, defining the problems and prioritizing solutions.

SIU challenges are numerous, but the priorities came out as: 1) reductions in SIU staff while FWA volume is increasing, 2) lack of quality leads, 3) variability in investigator speed and competence, 4) not enough investigators to handle all the leads that should be thoroughly reviewed, 5) and corporate pressures for SIUs to be more cost-effective.

Two technical priorities came out of the group’s working sessions. The first was the need to automate first-line investigations that currently take up to a few days to execute and are highly variable based upon the seniority and skill of the investigators. Second was the need to have single-point access to comprehensive provider data without spending hours Google searching.

The 4L team took the group priorities and worked on developing new tools to add to the existing 4L SIU Hub that aggregates and packages FWA leads into an easy-to-use lead management system. The result was the development of a suite of agentic AI tools called Investig8 AI™ Agent and Investig8 AI™ Assistant designed to condense a two-day first-line investigation into about 10 minutes of investigator time with enough data to make a go/no-go decision on whether to open a case. Investig8 AI Agent mimics the tasks of an experienced fraud investigator and provides a comprehensive case outline with supporting evidence in just a few minutes. The Investig8 AI Assistant provides investigators with an investigation-specific LLM platform to ask key drill-down questions aligned with the Agent case overview to make decisions, download provider and claims-related evidence, and move on to the next file. This use of patent-pending agentic AI technology provides at least a 20- fold productivity increase around first-line investigations.

If you are a health plan, TPA or self-insured senior executive, email Fast@4LData.com to learn more about 4L SIU Hub, Investig8 AI and other tools to improve your SIU productivity and efficiency.

Payment Integrity Begins And Ends With Provider Integrity.

Health plans need help. Now. The legacy of antiquated claims systems, labor-intensive processes, expanding compliance risk, escalating MLRs, and inflated administrative costs is unsustainable.

If you are a health plan, TPA or self-insured senior executive, email Fast@4LData.com to discuss the technical and financial power to break out of incrementalism and into high performance.

Incrementalism Is The Enemy.

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THE BLIND SPOT ENDS HERE.

Perspectives

Health Plans Need Help. Incrementalism Is The Enemy.

The legacy of antiquated systems and labor-intensive processes is unsustainable.

Learn More →

Provider Data Accuracy Is Attainable.

Effective credentialing must be continuous and automated, not episodic and manual.

Learn More →

SIUs Can't Keep up with Investigations. Help Is Here.

Manual investigation processes represent a critical bottleneck for fraud detection.

Learn More →

Payment Integrity Begins and Ends with Provider Integrity.

True payment integrity requires comprehensive provider intelligence.

Learn More →

Stop paying for what disconnected systems can't see.

Discover how integrated provider and payment integrity can prevent fraud, waste, abuse, error, and overpayments and reduce total operating costs in real-time. Prevent FWA. Prevent overpayments. Prevent wasted time and money in the SIU. NOW…with the 4L Provider & Payment Integrity Solution.

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