Killing Pay-and-Chase: Lyric Brings Human Review to Real-Time Claims

NASHVILLE, Tenn. – October 29, 2026 – In the labyrinthine world of healthcare economics, few processes are as universally despised as the "pay-and-chase" model. For decades, health insurers have relied on a fragmented system of paying medical claims quickly to meet regulatory deadlines, only to audit them months later. When errors or overpayments are inevitably found, a costly, abrasive clawback process begins. But as artificial intelligence reshapes the boundaries of operational efficiency, the intersection of algorithmic speed and human expertise is offering a compelling alternative.

Lyric, a Nashville-based healthcare decision intelligence company, recently announced a significant expansion to its Lyric42 platform, aiming to dismantle this retrospective recovery model. By integrating human expert review directly into real-time claims adjudication workflows, the company is bridging the gap between automated processing and nuanced clinical judgment. Under criteria defined by individual health plans, the system can now intelligently detect, prioritize, and temporarily pend complex claims, routing them to specialized reviewers before a final payment decision is made.

The move highlights a broader structural shift in healthcare administration: moving payment integrity "upstream." By addressing complexities before funds ever leave the health plan, the industry is attempting to solve one of its most pressing financial and relational friction points.

Dismantling the 'Pay and Chase' Cycle

The traditional post-payment audit is a blunt instrument. It costs providers millions in administrative expenses annually and strains the already fragile relationship between hospitals and payers. Health plans, meanwhile, spend vast resources trying to recover funds that have already been disbursed.

Lyric’s new capabilities attempt to short-circuit this cycle. The first product enabled under this framework is Coding Review, which targets highly complex billing scenarios that often trip up automated systems, such as intricate modifier usage and procedure relationships. Instead of allowing a potentially flawed claim to pass through for the sake of speed, the platform flags it and routes it to a human expert.

“The future of payment integrity isn’t about adding more edits or more reviews. It’s about determining the right action for each claim, at the right point in the process, and continuously learning how to make more of those decisions earlier,” said Brian Berkowitz, Chief Product Officer at Lyric.

Berkowitz noted that these new capabilities bring expert judgment into the set of actions the platform can orchestrate, helping health plans make more accurate decisions while the claim is still actively being processed. The goal is to progressively shift appropriate decisions from post-pay review to pre-pay review, ultimately saving both payers and providers the headache of retrospective reconciliation.

Human-in-the-Loop: The Antidote to Algorithmic Anxiety

As artificial intelligence becomes ubiquitous in insurance operations, it has faced significant public and regulatory pushback. Purely automated claim denials have sparked lawsuits and accusations that algorithms are practicing medicine without a license. Here, the "human-in-the-loop" approach serves as both an ethical safeguard and an operational necessity.

Lyric’s architecture operates on a governed AI model. The system relies on nurses, auditors, and certified coders to apply plan policies, CMS guidelines, and other regulatory frameworks to the pended claims. The AI does the heavy lifting of sorting, prioritizing, and surfacing the necessary contextual data in milliseconds, but the final recommendation on complex edge cases is guided by a human professional.

Crucially, this hybrid model acts as a continuous learning loop. When clinical experts review a pended claim, their outcomes reveal patterns. Data science teams can then translate these validated manual review findings into repeatable, automated pre-pay edits. As the algorithm learns from the human experts, health plans can move those specific decisions further upstream into the automated workflow, preserving manual review capacity for only the most novel or ambiguous cases.

This "shift-left" strategy ensures that the system's automated capabilities continuously improve based on real-world clinical input, mitigating the risk of runaway algorithms while scaling the efficiency of human oversight.

Upstream Audits and the Revenue Cycle Balancing Act

While the benefits to health insurers are clear, the impact on healthcare providers requires a more nuanced examination. Hospital revenue cycle management (RCM) teams have historically viewed pre-payment audits with deep suspicion. The American Academy of Family Physicians and other industry groups have long argued that indiscriminate pre-pay audits disrupt business operations, delay cash flow, and create immense administrative burdens.

State insurance commissioners and CMS Medicare Advantage guidelines mandate strict prompt-pay turnaround times. Clean claims must be processed within tight windows, and any system that pauses adjudication risks violating these statutory requirements. Historically, being placed on a pre-payment audit could delay a hospital's payment by 90 to 120 days.

"Any time you introduce a 'pend' status into the adjudication workflow, you are playing a dangerous game with hospital cash flow," noted one healthcare revenue cycle director at a major Midwestern health system. "If this technology is used as a dragnet to delay payments, it will be fiercely opposed. But if it is truly targeted and resolves issues in days rather than months, it might be an acceptable trade-off."

Lyric’s platform attempts to thread this needle by utilizing AI to prioritize and manage pended claims rapidly, ensuring they keep moving through the queue. For providers, the ultimate value proposition is a reduction in downstream friction. Resolving a complex coding issue during adjudication may add a slight delay upfront, but it produces a cleaner final payment. Avoiding the surprise of a clawback letter six months later—and the subsequent appeals process—could ultimately save providers significant administrative overhead.

The Competitive Landscape of Payment Integrity

The payment integrity market is highly competitive, dominated by massive legacy players like Cotiviti and Optum, alongside a rising tide of AI-first startups. Payers frequently use multiple vendors to patch together pre-pay and post-pay solutions.

Cotiviti and Optum both offer robust payment policy management and coding validation tools, heavily emphasizing the avoidance of payment errors before claims are paid. However, industry analysts at KLAS Research have noted that while these legacy vendors offer broad portfolios, the complexity of integrating real-time insights without disrupting payer workflows remains a significant hurdle.

Lyric is attempting to differentiate itself not just through the accuracy of its AI, but through the seamless orchestration of human expertise within the real-time workflow. By allowing health plans to define the specific rules for routing claims and integrating this directly into the Lyric42 ecosystem, the company is offering a more customizable, transparent alternative to "black box" AI solutions.

The initial rollout of Coding Review is just the beginning. The company has announced plans to expand these expert review capabilities into Coordination of Benefits, DRG validation, and itemized bill audits. As these traditionally downstream activities migrate into pre-pay workflows, the fundamental mechanics of healthcare reimbursement are being rewired. By balancing the speed of modern computing with the irreplaceable nuance of clinical judgment, the industry is taking a vital step toward a more transparent, efficient, and equitable financial ecosystem.