New capability brings payment integrity into provider recommendations within the WayFinding® platform before care begins

Transcarent, the first agentic AI-powered health and care platform, today announced that its WayFinding® platform is the first to incorporate payment integrity into provider recommendations before care is delivered. This first-of-its-kind approach moves payment integrity from a back-end claims review function to a front-end care decision, directing Members to high-quality clinicians with responsible billing practices while giving employers a new opportunity to prevent unnecessary healthcare spending.

The innovation addresses the growing employer challenge of inappropriate billing. From routine visits coded as complex encounters to procedures billed at inflated levels, upcoding and inaccurate billing can drive up healthcare costs without improving care. A recent analysis found that increased coding of people as medically complex contributed an estimated $942 million in additional spending between 2023 and 2025, without evidence of a corresponding increase in care complexity.

The WayFinding platform already uses clinical quality scoring to help Members identify top providers. The new provider payment integrity capability adds another critical dimension: how appropriately providers have historically billed and coded for the care they deliver. By incorporating these payment integrity signals into provider recommendations, the WayFinding platform directs Members to high-quality providers who not only deliver excellent care but also demonstrate fair, appropriate, and responsible billing practices.

"For too long, payment integrity has been about identifying unnecessary costs after care has already been delivered," said Snezana Mahon, PharmD, President of Transcarent. "We're changing that equation. The WayFinding platform already helps people find high-quality doctors. Now, we're making those recommendations even smarter by considering how clinicians bill for care. It's a fundamentally different approach that encourages Members to make more informed decisions while giving employers an opportunity to prevent unnecessary spending before it happens."

Bringing Payment Integrity into Care Decisions

Powered by AI and advanced analytics, Transcarent draws on its proprietary analysis of more than 100 billion claims, including nearly all Centers for Medicare & Medicaid Services (CMS) claims and approximately 75% of commercial claims. This comprehensive data enables Transcarent to evaluate provider billing and coding patterns alongside quality, cost, clinical appropriateness, and site of care, using more than 300 measures across spanning 40-plus specialties, with insights refreshed quarterly.

Beginning January 1, 2027, this intelligence will be incorporated into provider recommendations. By turning claims insights into action earlier in the healthcare experience, Transcarent is giving employers a proactive way to address unnecessary spending before it occurs.

About Transcarent

Transcarent makes it easier for people to access high-quality, affordable care with the WayFinding® platform, powered by agentic AI, which not only provides better information but does the work for you. Transcarent brings medical, pharmacy, and point solution benefits together in one experience — including transparent pharmacy care, 2nd.MD expert medical opinions, virtual primary care, surgery and cancer Centers of Excellence, and specialized support for weight health. More than 1,700 employers and health plans trust Transcarent to support 21 million Members with a better experience, more access to quality care, and lower costs. Learn more at transcarent.com.

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“For too long, payment integrity has been about identifying unnecessary costs after care has already been delivered. We’re changing that equation.” — Snezana Mahon, PharmD, President of Transcarent