Payer Solutions

Smarter Payer Operations Start Here.

Reimagine your payer operations with intelligent automation, analytics, and secure, scalable digital infrastructure.

Challenges Faced By Payers
What To Do About Them
How We Can Help You
Accelerators
Integrations
Why Choose Pegasus One

What’s Holding Healthcare Payers Back

Disconnected Systems Limit Member Insight

Siloed platforms prevent a complete view of the member, hurting coordination, personalization, and risk management.

Missed Opportunities in AI and Analytics

Despite rich data, many payers still struggle to operationalize AI for fraud detection, risk scoring, claims optimization, and personalized outreach..

Claims Denials and Rework Drain Resources

High denial rates force costly appeals, slow down cash flow, and create friction with providers and members alike.

Outdated Technology Slows Innovation

Legacy systems block digital transformation, data interoperability, and the ability to adapt to market and regulatory changes.

Compliance Burden Continues to Grow

Navigating shifting regulations demands constant vigilance, adding risk and administrative overhead.

Rising Member Expectations Raise the Stakes

Today's members expect seamless, digital-first experiences — not confusing portals, long wait times, and paper-heavy processes.

Conquer “Payer Headaches” With Novel AI-First Solutions

Unified, Intelligent Platforms

We unify fragmented data sources (EHRs, claims, eligibility systems, CRM, IoT devices) into a 360° member view, enabling smarter care coordination, analytics, and reporting.

AI-Powered Fraud Detection and Risk Management

Our advanced AI models detect patterns of fraud, waste, and abuse early — protecting revenue, enhancing underwriting decisions, and strengthening financial performance.

Revamped Claims Processing with AI and RPA

We streamline claims intake, validation, adjudication, and payment using AI and RPA — cutting turnaround times, reducing errors, and boosting first-pass resolution rates.

Legacy Modernization For A Future-Ready Payer Platform

We replace aging legacy systems with cloud-based, multi-modal AI-First Payer Solutions that adapt to member workflows — giving them speed, flexibility, and security while adhering to strict compliance policies for payment systems.

Regulatory Compliance & Reporting

We help payers stay audit-ready with automated compliance checks, seamless reporting for CMS mandates, and secure data handling aligned to HIPAA, GDPR, and more. Automated reporting tools simplify the submission of regulatory filings, reducing the risk of non-compliance and penalties, while improving audit readiness.

Member Experience & Engagement

Improving the member experience is at the heart of our solutions. Our suite of member engagement tools, including self-service portals, mobile apps, and personalized communication, enhances member satisfaction by providing easy access to plan information, claims status, and health resources. This leads to greater retention rates and improved outcomes by fostering better relationships between payors and members.

We offer Payers a robust suite of offerings to get started with their transformation journey

FHIR Integration Services

Turn interoperability into a strategic advantage. We help payers unlock real-time data exchange across EHRs, claims systems, and partner platforms using modern FHIR frameworks — improving automation, care coordination, and regulatory alignment.

Member Data Exchange and Claims Automation

Streamline member data exchange and automate claims processes with FHIR-based infrastructure that reduces manual intervention and accelerates payouts.

Prior Authorization and Care Coordination

Simplify prior authorizations and support proactive care coordination by connecting clinical and administrative data — in real time.

Provider Directory Management

Maintain an accurate, compliant, and easy-to-navigate provider directory that supports transparency and interoperability across your network.

Consulting and Operations

Your roadmap to compliance, efficiency, and growth. Our strategic advisory services help you navigate CMS mandates, optimize core operations like claims and data governance, and modernize aging systems with clarity and control.

FHIR Roadmap and CMS Compliance Strategy

Navigate evolving CMS mandates with clarity. We’ll help you define a FHIR roadmap that aligns with your compliance goals and tech maturity.

Data Governance and Security Advisory

Improve how your organization handles sensitive healthcare data with security-first data governance frameworks built specifically for payers.

Claims Processing Optimization

Optimize your claims processing systems to reduce cycle times, minimize errors, and free up your teams to focus on higher-value work.

Digital Development

Deliver intuitive, modern digital experiences that engage members and empower your teams. From self-service portals to intelligent analytics platforms, we build custom solutions that reduce friction, increase transparency, and drive better health plan outcomes.

Member Engagement Portals and Mobile Apps

Deliver seamless, personalized digital experiences that empower members to take control of their health. Our intuitive portals and mobile apps offer real-time access to claims, benefits, providers, and wellness tools — all while reducing support costs and boosting member satisfaction.

AI-Powered Claims Analytics and Fraud Detection

Accelerate claims decisions and protect your bottom line with advanced AI and machine learning. Our analytics solutions flag anomalies, predict denials, and detect fraudulent patterns in real time — giving you actionable insights and reducing unnecessary payout leakage.

Value-Based Care and Risk Management Platforms

Enable smarter contracting and better health outcomes with platforms designed for value-based care. We help you track performance, stratify risk, and align incentives across providers — all while ensuring compliance and maximizing shared savings.

Data Analysis and AI

Transform your data into real-time insight. We design AI and analytics solutions that uncover risk, streamline documentation, and guide smarter population health decisions — all while keeping compliance and scalability at the core.

Predictive Analytics for Population Health

Anticipate population health trends with predictive analytics that help drive proactive interventions and resource allocation.

AI-Driven Risk Adjustment and Quality Reporting

Automate risk adjustment and streamline quality reporting with AI tools that continuously adapt and learn — improving accuracy without adding overhead.

Accelerated Innovation With Pre-Packaged Solutions

Go from start to finish, blazing fast. Utilize our AI powered accelerators to speed up your project – all tested for scalability, security and compliance.

Accelerator > Provider Solutions

Cognitive Wellness Accelerator for Aging Adults

Ideal for wellness platforms, healthcare providers, retirement communities, and digital health innovators, this solution combines engaging brain-training games, lifestyle insights, and real-time user analytics.

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Accelerator > Integration Solutions

Healthcare Data Insights for Home-Based Care Providers

This accelerator unifies data silos, ensures report accuracy before business hours, and delivers insights to support compliance, optimize care delivery, and improve margins.

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Accelerator > Payer Solutions

Insurance & Financing Platform

This accelerator is purpose-built for health insurance brokers, TPAs and offers a modular foundation for managing insurance quotes, agent workflows, credit applications, loan offers, and applicant records across web and mobile.

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Accelerator > Payer Solutions

Modular Payer Platform For Enrollment, Billing & Support

This accelerator supports healthcare payers and third-party administrators (TPAs) in transforming enrollment, billing, and member services.

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Accelerator > Payer Solutions

Modular Payer Platform For Enrollment, Billing & Support

This accelerator supports healthcare payers and third-party administrators (TPAs) in transforming enrollment, billing, and member services.

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Accelerator > Payer Solutions

Modular Payer Platform For Enrollment, Billing & Support

This accelerator supports healthcare payers and third-party administrators (TPAs) in transforming enrollment, billing, and member services.

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Accelerators built for your most urgent needs

Our accelerators cater to the most sought after technology solutions in the healthcare industry.

Offer more to your clients

An AI-first End-to-End Suite Of Healthcare Technology Enhancement Suite.

Allscripts
Integration

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Assistive
Technology

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Medical Imaging
Solutions

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Electronic Health Records
(EHR/EMR)

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E-prescribing
(eRx)

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Health Information Exchange
(HIE)

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Hospital Management
Solutions

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HL7
Interface

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Laboratory Information
Management (LIM)

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Mirth Integration
& Development

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Pharmacy Management
Software

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Revenue Cycle
Management

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Telehealth
Solutions

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Veterinary Hospital
Management

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Break Down Data Silos with Seamless Interoperability

Healthcare data shouldn’t live in silos. We help providers truly connect the dots — across Epic, Cerner, Meditech, and beyond. Whether you’re looking to build SMART on FHIR apps that plug directly into your EHR or expose secure FHIR APIs for internal teams and third-party apps, we make interoperability painless. From bulk data export for analytics to single-patient queries at the point of care, our FHIR-first approach ensures you’re always ahead of compliance — and competition.

Share Data Instantly and Securely

Connect systems with FHIR

Streamline Workflows

Tools/Integrations We Offer

EHR/EMR

Communication Integration

Cloud Platforms Supported

Automation

Mobile Platform Integrations

Compliances

Explore AI-Powered Payer Solutions Made For The Future

Transformation Stories

Explore some of Pegasus One’s success stories.

Remote Patient Monitoring (RPM) Implementation
Case Study
FHIR-Based Care Coordination Platform
Case Study
AI-Powered Claims Analytics & Fraud Detection
Case Study
FHIR-Based Blood Glucose Monitoring & PHR Integration
Case Study

Why choose us

When it comes to healthcare payers, we understand the balance you’re managing — reducing cost, meeting regulatory requirements, and improving member outcomes, all at once.

Here’s what makes us uniquely positioned to help:

FHIR-Driven, Payer-Specific Solutions

We design integration strategies and tools specifically for payer workflows — not repurposed from provider use cases. Our solutions are tuned to claims logic, authorization flows, and compliance requirements.

Compliance Isn’t an Afterthought

We’ve delivered solutions that align with CMS, ONC, and NCQA standards — ensuring your digital transformation doesn’t just innovate, but also stays audit-ready.

Proven Experience Across the Stack

From building AI fraud detection systems to developing member portals and care management dashboards, we bring technical depth and real-world implementation success.

Data Strategy with Business Impact

We bridge the gap between your data and your goals — whether that’s risk adjustment, better quality scores, or smarter engagement strategies.

Secure, Scalable, Sustainable

Whether modernizing legacy infrastructure or launching something new in the cloud, our solutions are built to grow with your organization — securely and cost-effectively.

Got Questions? Let’s Clear Them Up.

We understand healthcare payer challenges inside and out. Here’s everything you need to know to move forward with confidence — faster claims, smarter systems, happier members, and better outcomes.

Claims process automation uses technologies like AI, RPA, and machine learning to streamline claims intake, validation, adjudication, and payment. This reduces manual effort, cuts errors, improves turnaround times, and boosts first-pass resolution rates — leading to faster reimbursements and lower administrative costs.

Revenue cycle optimization focuses on improving every step of the payer financial process — from claims submission and denial management to reimbursements and cash flow forecasting. It reduces leakage, enhances collections, and provides better financial visibility for smarter decision-making.

By offering seamless digital-first experiences — personalized portals, mobile apps, self-service options, and faster customer service — payers can increase member satisfaction, loyalty, and retention while reducing support costs and improving HEDIS scores.

Data interoperability means different systems — claims, clinical, eligibility, CRM, and others — can share and use information seamlessly. For payers, it enables a full 360° view of members, drives better care coordination, strengthens analytics, and supports regulatory compliance.

AI models can analyze claims and provider patterns in real-time to flag anomalies, predict high-risk activities, and detect potential fraud, waste, or abuse early. This allows payers to intervene faster, recover lost revenue, and reduce exposure to financial risks.

Our solutions automate compliance tracking, reporting, and audit preparation. We ensure systems meet HIPAA security requirements, CMS interoperability rules, and evolving mandates — reducing administrative burden and minimizing the risk of costly penalties.

Yes. We specialize in building flexible integration layers and middleware that connect modern cloud applications, AI tools, and digital experiences to your legacy core systems — maximizing existing investments while enabling innovation.

Most clients begin seeing measurable benefits — such as improved claims processing times, fewer denials, increased member satisfaction, and better financial reporting — within 6 to 12 months depending on the project scope.

Pegasus One At
A Glance

Inc 5000

5-time Inc 5000 honoree (2019, 2020, 2021, 2023 & 2024)

Rating Star New

Rated 4.9 stars by clients on Clutch

AI Inner Circle

Part of the prestigious Microsoft AI Inner Circle program.

Healthcare Gov Covered California

Part of multiple prestigious civil-society betterment projects

Inc 5000 Microsoft Gold Amazon Parnet Company

Microsoft Solutions Partner and AWS Advanced Consulting Partner

Webby Awards

Apps consistently featured by leading design awards.

TALK TO OUR EXPERTS