Gynisus
Gynisus offers SPAI PI, an AI-driven payment integrity platform that automates DRG audits, coding edits, clinical integrity checks, medical necessity reviews, and fraud, waste, and abuse detection for healthcare payers. The platform flags claims at both claim and line levels with detailed rationale to minimize appeals. Its multi-modal pipeline integrates claims data with clinical understanding to uncover savings opportunities and ensure coding guideline compliance.
- Insurance Technology
- Healthcare Technology
- Artificial Intelligence
- Regulatory & Compliance Technology
- Software Only
- Data & Analytics
- Digital Health
- Enterprise Software
Funding
Raised to date
$50KRaised to date based on public sources. This may differ from the amount the company actually raised and is based only on what is publicly available on the internet.
Founders
Israel Meizner
Co-Founder
Gynisus • Co-Founder
Zoya Gordon
Co-Founder
Gynisus • Co-Founder
Product
Problem
Healthcare payers face challenges in accurately processing medical claims due to coding errors, guideline violations, and potential fraud, waste, and abuse (FWA). Traditional methods often lack the precision needed to identify discrepancies, leading to overpayments and financial losses. Manual audits are time-consuming and prone to human error, hindering efficient payment integrity.
Solution
Gynisus offers an AI-driven payment integrity platform, SPAI PI, designed to automate and enhance the accuracy of medical coding and claims processing. The platform leverages advanced AI models to perform end-to-end DRG audits, automated coding edits, clinical integrity checks, medical necessity reviews, and FWA detection. By integrating claims data with clinical insights, SPAI PI identifies discrepancies, coding errors, and potential instances of fraud, waste, and abuse. The system provides claim-level and line-level flags with detailed explanations, enabling payers to optimize accuracy, maximize savings, and ensure compliance with coding guidelines and medical necessity standards.
Target Audience
The primary target audience includes healthcare payers, insurance companies, and self-insured employers seeking to improve payment accuracy, reduce costs, and prevent financial losses due to coding errors and FWA.
Features
- End-to-end automated DRG auditing that identifies inaccuracies in DRG assignments based on industry grouping methodologies, including a recommended DRG correction.
- Automated coding edits that streamline PTP editing validation, MUE, and AOC checks, ensuring fast, precise, and reliable results.
- Clinical integrity analysis that uncovers savings opportunities by evaluating the relationships between conditions and procedures, flagging contradictory indications and promoting evidence-based reporting.
- Medical necessity reviews that identify patterns of clinical waste related to unnecessary tests, equipment, services, and procedures.
- Fraud, waste, and abuse (FWA) detection that leverages AI to identify questionable behavior patterns among providers and patients.
- SPAI PI MRR (Medical Record Retrieval and Review) automates medical record retrieval from Epic or Cerner and provides unbiased review reports.
- Multi-modal pipeline integrates claims data with clinical understanding to evaluate relationships between conditions and procedures, with optional inputs including claims history, Rx, labs, and vitals.