- Claims
- Intake, edits, adjudication, pends, payment and appeals as a flow.
- Rehearses: New edits, auto-adjudication thresholds, agent rollouts.
- Prior authorization
- Request volume, clinical review capacity, model decisions and turnaround.
- Rehearses: Policy changes, gold-carding, model decision thresholds.
- Care management
- Outreach, enrollment, engagement and outcomes across programs.
- Rehearses: Program design, caseload sizing, targeting rules.
- Pharmacy benefit
- Formulary rules, adherence, utilization and cost trend.
- Rehearses: Formulary changes, adherence programs, rebate scenarios.
- Provider network and contracting
- Access, referral patterns, contract terms and provider behavior.
- Rehearses: Network changes, contract negotiations, value-based arrangements.
- Member services and contact centers
- Call and chat demand as it is created upstream by denials, mailings and policy changes, plus staffing, deflection and resolution.
- Rehearses: Removing a call driver at its source, assistant rollouts, open enrollment staffing.
- Revenue cycle
- Charge capture, coding, billing, denials and collections.
- Rehearses: Denial prevention, coding automation, payer rule changes.
- Clinical operations and capacity
- Beds, clinics, staff, scheduling and patient flow.
- Rehearses: Capacity plans, scheduling rules, surge response.
- Population health
- Risk trajectories, interventions and long-run cost across populations.
- Rehearses: Prevention investments, targeting, outreach cadence.
- Fraud, waste and abuse
- Billing behavior, collusion patterns and detection response.
- Rehearses: Detection rules, model thresholds, investigation capacity.
- Regulatory reporting
- Measure logic, data lineage and reporting deadlines.
- Rehearses: Rule changes, measure updates, audit readiness.
- Event fabric
- Claims, authorizations, care management, pharmacy, contact center, revenue cycle and clinical operations as one time-ordered stream.
- Process discovery
- Process mining reconstructs how work actually flows, including the exceptions, rework loops and hand-offs nobody documented.
- Simulation engine
- Discrete-event and agent-based simulation where members, providers, staff, bots and AI systems are agents with their own behavior.
- Causal engine
- Counterfactual estimates for every intervention, with uncertainty ranges rather than single numbers.
- Synthetic and privacy layer
- Synthetic populations that keep the statistics and lose the identities, so no protected health information circulates.
- Calibration
- Continuous reconciliation against live telemetry, with drift alarms that pause any scenario the twin can no longer vouch for.
- Decision desk
- An executive interface that answers in ranges, confidence and cost, and records who approved which scenario for the real system.
The value is the experiments that never had to run on real members, real providers and real money: policy changes tried at every setting, automation rolled out to the twin before the floor, staffing and network decisions made on evidence instead of instinct, and every AI system on the roadmap measured in the twin before it earned a place in production.