TL;DR: Fuse offers AI-powered analysis of healthcare contracts and payments to help providers detect underpayments and collect the revenue they’re owed from insurers.

❌ Problem

Our “aha” moment came when healthcare provider execs repeatedly told us they had no idea if their revenue was accurate. One even described their insurance claims process as a “black hole”.

Several factors contribute to this issue:

1. Growing usage of AI. Insurers are using sophisticated models to analyze claims and find ways to subtly underpay.
2. Too many contracts: An average hospital has over 50 contracts with insurers with varying reimbursement rates for the same procedure, making payment accuracy verification costly and near impossible.
3. M&A wave: Mergers are forcing providers to consolidate contracts and revenue tracking systems, adding further complexity.

As a result, providers spend months analyzing revenue and chasing payments, forfeiting up to 11% of topline revenue if they cannot afford the overhead to do so.

With provider operating margins already negative since COVID-19, the situation creates severe margin compression and cash flow risk.

Solution

We use LLMs to extract data from the stacks of contracts that dictate provider payment terms from insurers. We reconcile the data against remittances to identify underpayments and auto-generate appeals.

Our mission is to level the playing field for providers with AI-powered contract analytics. Beyond this, we want to aid the transition towards Value-Based Care by powering sophisticated contract modeling as payment models become even more complex.

Team

Our team specializes in complex financial data analytics. We previously co-founded a business that grew from $0 to $6M ARR in 12 months, developing large-scale data models for payment and credit analytics that outperformed major players like Experian.

Oscar (CTO) was an academic who completed a PhD and postdoc in Machine Learning at Cambridge. He’s worked in research divisions for companies like McLaren F1, and brings expertise in building top performing data models in highly regulated industries.

Sho (CEO) met Oscar during their first week of undergrad at Cambridge. He’s a repeat entrepreneur and closed a $100k contract within a year for his first company, and has worked on data analytics projects for some of the largest providers and insurers in the world at McKinsey.

🙏 Our Ask

If you know senior finance execs in healthcare systems or partners at healthcare PE firms please do connect us! founders@fuseinsight.com