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Claims are screened before approval, not audited months after they've already paid.
FWA Detection & Claim ReviewHealthOS Sentinel: Catch It Before It Pays,
HealthOS Sentinel: Catch It Before It Pays,
Not After
Identify fraud, waste, abuse, and payment anomalies before payments are made, with AI PASS working directly against the same claims record CAPS adjudicates, instead of a recovery audit run months later.
HITRUSTSOC 2 Type IICMSHL7 FHIR
Review QueueSIU CasesOutliersRecovery
Prevented YTD$6.8M
Detection Accuracy95%+
Open Cases14
CLM-9920 · $4,200Duplicate billing detected
HoldCLM-9901 · $1,850Unusual coding pattern
ReviewProvider Outlier PR-118Billing diverges from peer group
FlaggedAIAI PASS screened 84,200 claims this month and held $820K in improper payments before they left the door.
Workspace Overview
What Is HealthOS Sentinel?
HealthOS Sentinel is the workspace where fraud, waste, and abuse are caught before a claim pays, not recovered after the fact. It screens claims using the same adjudication data CAPS is already working with, so leakage gets caught at the point of decision, and SIU teams work from a prioritized case queue instead of a spreadsheet.
Integrated With CAPS
Screening runs directly against the same adjudication record, with no separate data feed.
AI PASS Explains Every Flag
Reviewers see the specific pattern behind a risk score, not a black-box number.
Platform Foundation
Leakage Caught at the Point of Decision, Not the Point of Recovery.
Recovering an improper payment always costs more than never making it. HealthOS Sentinel runs on the same secure, shared core as every HealthOS workspace, so screening happens where the decision is made.
Immutable Security & Audit
Every flag, review, and resolution is logged, supporting HITRUST and SOC 2 Type II obligations by default.
Shared Data Core
Screening runs directly against the same claims record CAPS adjudicates, in real time.
AI PASS Embedded Intelligence
Duplicate billing, coding anomalies, and provider outliers are flagged with explainable reasoning attached.
Inside Sentinel
Five Modules. Everything an SIU or Payment Integrity Team Runs On.
Pick a module to see what your team actually touches inside it.
Pre-Payment Review
Every claim is screened for duplicate billing, unbundling, and known anomaly patterns before it's approved for payment.
Duplicate Billing DetectionUnbundling DetectionRisk ScoringCAPS Integration
Claims Screened MTD84,200
Flagged1,140
Prevented This Month$820K
CLM-9920 · $4,200Duplicate billing detected
HoldCLM-9901 · $1,850Unusual coding pattern
ReviewCLM-9887 · $980Provider outlier detected
ReviewHow Work Moves
Pre-Payment Review, From Flag to Resolution.
Most flags never make it anywhere near a payment.
A claim in the CAPS adjudication queue trips a payment integrity rule or anomaly pattern.
AI PASS assigns a risk score based on the specific pattern detected and historical outcomes for similar claims.
Higher-risk claims route to an SIU reviewer with the relevant claims history already attached.
The claim is approved, adjusted, or denied, and the outcome feeds back into future risk scoring.
The Intelligence Layer, Inside Sentinel
Catching Patterns a Person Reviewing One Claim at a Time Would Never See.
AI PASS detects duplicate billing, coding anomalies, and provider outliers across the full claims population, and attaches the specific reasoning behind every flag so reviewers can verify it.
Learn more about AI PASSLive decision intelligence● Active
Claim CLM-9920 · $4,200On Hold01 / Review
Analysis completeMatching service line billed 6 days earlier by the same provider · Same member, same procedure code · Duplicate billing pattern confirmed against claims history.
RecommendationHold pre-payment and open an SIU case with both claim records attached.
Confidence 95%
Why HealthOS Sentinel?
The Numbers Behind the Console.
What health plans and government programs typically see after moving payment integrity onto this workspace.
95%+Detection accuracy
98.7%Compliance Audit Score
2–5xFaster Turnaround
Why Sentinel
What Changes When Screening Runs Before Payment.
The difference shows up in how much never has to be clawed back.
The Old Way
- Fraud, waste, and abuse are caught in a recovery audit months after payment.
- SIU teams work from a spreadsheet instead of a prioritized case queue.
- Provider outliers are found manually, if they're found at all.
- Recovering an improper payment costs more, and takes longer, than preventing it.
On Sentinel
- AI PASS screens every claim before payment, catching leakage at the point of decision.
- SIU teams work a prioritized case queue with evidence already attached.
- Provider outliers are surfaced automatically through peer benchmarking.
- Post-payment recovery workflows remain available for anything pre-payment review doesn't catch.
Security & Compliance
Built to the Standards Your Compliance Team Already Holds You To.
Role-based access control, encryption in transit and at rest, and a complete audit log across every module — the same baseline for every HealthOS workspace.
HITRUSTSOC 2 Type IINCQAHL7 FHIR R4CMS Interoperability RuleEDI 837 · 835 · 270 · 271
FAQ
Frequently Asked Questions.
Does this replace post-payment recovery entirely?
No. Pre-payment review is designed to catch the majority of leakage before it pays, while post-payment recovery workflows remain available for anything that still needs it.
Can reviewers see why a claim was flagged?
Yes. Every flag includes the specific pattern and comparison data behind the risk score, so SIU reviewers can verify the reasoning rather than act on a black-box number.
Does Sentinel require HealthOS CAPS to function?
It runs most effectively integrated with CAPS, screening claims at the point of adjudication, but the module can also review claims data from other core administration systems.
Is HealthOS Sentinel secure and compliant?
Yes. Sentinel aligns with HIPAA, HITRUST, SOC 2 Type II, and CMS requirements, with a complete audit log across every case.
One Console, One Suite
Six Workspaces. One Record.
Every HealthOS workspace reads and writes to the same core. Start with Sentinel, connect the rest whenever your team is ready.
Get Started
See HealthOS Sentinel in the context of your operations.
Bring your line of business and your hardest workflow — we’ll show you how it runs on one intelligent platform.
