We enable Commercial Group, Medicaid, and ACA plans to identify Medicare beneficiaries in a timely manner and pay claims accurately. Through a combination of precise pre‑payment validations, including Section 111 processes, and post‑payment Coordination of Benefits (COB) recoveries, Pareto drives operational efficiency and medical claims savings.
We combine payment analytics, data science, and regulatory expertise to support end-to-end detection, claims prevention across pre- and post-payment workflows, and recovery of overpayments.
The Pareto PaymentIntegrityIQ solution supports operational and compliance leaders at health plans looking to reduce and improve claims payment accuracy from the onset.
Recover dollars without straining provider relationships.
Follow CMS guidelines and ensure payment accuracy.
Detect and prevent recurring payment issues.
Ensure compliance with CMS Section 111 reporting requirements, automate MSP and COB validation, and streamline data submissions
Pareto goes beyond point solutions and siloed vendors. Our configurable payment integrity processes are designed to improve medical claims accuracy and produce measurable, auditable results.
Fix the breakdowns that cause recurring claims overpayments driven by lagged Medicare eligibility information and complex Section 111 processes.
Navigate the complexities of Medicare regulatory requirements from detection to recovery to prevention.
Take advantage of tailored approaches, logic, and workflows for all lines of business.
Maintain compliance with CMS guidance, including Medicare Secondary Payer (MSP) requirements through Section 111 reporting.
Pareto PaymentIntegrityIQ specializes in ensuring accurate claims payments between health plans and Medicare; flagging dozens of common error types—from inaccurate Medicare eligibility to covered services.
Pareto PaymentIntegrityIQ combines analytics, compliance logic, and root cause resolution—not just identification and collection.
No. Pareto PaymentIntegrityIQ supplements and complements your internal teams and/or existing claims processing and recovery vendors.
Pareto’ supports Commercial Group, Medicaid, and ACA plans, with configurable payment integrity processes for each line of business.
Maintain regulatory compliance for accurate liability assignment.
Use accurate eligibility information before payment is released.
Identify and recover improper payments using post-pay analytics.
Understand where breakdowns occur—and how to keep them from happening again.
PaymentIntegrityIQ isn’t just about finding dollars. It’s about preventing future loss. That’s what Pareto’s payment integrity solution is made for.
Claims analytics identify overpayments and error-prone patterns.
You can validate flagged claims for accuracy and recovery eligibility.
Auditable workflows support provider outreach and collection with an audit-ready data output.
Root cause analytics improve processes before the next claim is paid.
Pareto supports Group Health plans to refine complex reporting processes or can fully take it on as a designated reporting entity.
Pareto often works as second or third pass vendor, as our nuanced solution and knowledge of Medicare regulatory complexities complement broader payment integrity activities.
Pareto workflows are built to minimize abrasion, ensure clarity, and deliver auditable outcomes.
Most partners launch in under 12 weeks, depending on data availability and scope.
Yes. PaymentIntegrityIQ validates the accuracy of medical claims payments against Section 111 information provided to and received from CMS. We can also perform a one-time operational review to validate mandatory Section 111 processes and identify issues without requiring plans to fully outsource the function.
The process of determining which payer is responsible for claims payments when multiple coverages exist.
CMS rules that determine whether Medicare is the primary or secondary payer for a beneficiary’s claims.
The practice of ensuring that claims are paid correctly by identifying, recovering, and preventing improper payments.
Prospective review of other insurance eligibility before payment is issued to prevent likely medical claims payment errors.
Retrospective review of paid claims to identify and recover overpayments in instances where improper primacy determinations were made.
Investigation to identify the underlying process or system failure that led to a claims payment error.
A CMS reporting mandate that requires health plans to report any additional insurance coverage their members have, so Medicare can determine the correct order of payer responsibility for Medicare-eligible individuals.
When another insurer has responsibility for a member's full or partial medical claim costs.
Pareto Intelligence is a healthcare analytics and technology company that helps health plans in government-sponsored markets improve financial performance and regulatory compliance. Our platform delivers actionable insights across premium reconciliation, risk adjustment, Stars, and member engagement—so plans can recover revenue, close gaps, and stay CMS-ready.
With solutions like PaymentIntegrityIQ, Pareto empowers teams to recover overpayments, automate Section 111 reporting, and strengthen MSP and COB accuracy—helping plans reduce leakage, improve audit readiness, and prevent future errors.
Fill out the form to take the first step toward reaching your goals. Share a few details so we can provide the right resources and support tailored just for you.
Fill out the form to take the first step toward reaching your goals. Share a few details so we can provide the right resources and support tailored just for you.
