Professional Services
Payer operations and core administration.
Technical and operational expertise for maintaining, validating, troubleshooting, and modernizing payer
operations. This is the work that sits underneath every interoperability program: whether a claim priced
correctly, why a payment moved after a release, and which layer of configuration actually caused it.
What this is not. This is not business process outsourcing, an outsourced claims
department, or staffing. The work is payer technology — configuration, validation, architecture,
and operational problem solving — performed alongside your team, not instead of it.
Service 07
Fee Schedule and Reimbursement Services
Fee schedule changes are among the highest-consequence configuration events a health plan performs, and
the blast radius is rarely obvious before the claims run. These engagements are about knowing what a
change will do before production finds out.
Analysis and loading
- Analyze current fee schedule configurations
- Load or update new fee schedules
- Validate effective dates
- Compare old and new reimbursement schedules
- Identify material payment differences
Validation and impact
- Create representative test scenarios
- Validate reimbursement calculations
- Review provider and contract dependencies
- Assess downstream claims impact
- Support implementation into the existing core administration platform
We work with the fee schedules, code sets, and contract terms a health plan already holds and is
licensed to use. Cloud Health Office does not supply proprietary fee schedules or licensed code sets as
part of an engagement, and payer-confidential reimbursement information is never published or exposed.
Service 08
Claims Repricing and Payment Validation
Expected-versus-actual reimbursement, at a scale that makes the answer trustworthy. The goal is to turn
“this payment looks wrong” into a specific, reproducible finding attributable to a specific
configuration layer.
Analysis
- Repricing analysis
- Expected-versus-actual reimbursement comparison
- Payment variance analysis
- Configuration defect identification
- Explanation of the pricing logic that produced a result
Testing and assurance
- Large-scale regression testing
- Claim scenario testing
- Validation before a production deployment
- Validation following a configuration change
- Documented findings your team can act on
Where it fits the engagement, Cloud Health Office technology can act as a testing, comparison,
simulation, or validation accelerator — running scenarios beside the core rather than in place of
it. It is not a replacement for contracted repricing networks, provider contracts, or third-party pricing
services.
See the public repricing tool →
Service 09
Core Administration Operational Support
Production-facing technical support across QNXT, Facets, HealthEdge, and other payer core administration
systems — the investigation and validation work, not the day-to-day operation of your department.
Investigation
- Configuration assessment
- Production issue investigation and triage
- Root-cause analysis
- Integration troubleshooting
- Payment discrepancy analysis
- Batch and interface analysis
- Vendor escalation support
Change and release
- Benefit and accumulator configuration review
- Provider reimbursement and contract configuration support
- Provider configuration and reference data
- Code-set and terminology updates
- Configuration-change validation and regression testing
- Pre-production payment comparison and post-deployment validation
- Operational workflow review and release readiness
- Modernization of manual payer workflows
QNXT carries the deepest practical experience, described on the founder page.
As everywhere else on this site, that is career experience — not a certification, partnership,
endorsement, or authorized-implementer relationship with any vendor.
When plans typically call
Before a change
Updating a fee schedule and need confidence that claims will reimburse correctly?
We analyze the configuration, build representative scenarios, and compare expected against actual
before the change reaches production.
After a release
Seeing unexpected payment differences after a configuration release?
We reproduce the variance, isolate the change that caused it, and document the finding with the claims
that demonstrate it.
Independent check
Need independent validation before moving a reimbursement change into production?
A second set of eyes on the configuration and the test evidence, written from the health plan's
perspective rather than the implementing party's.
Which layer?
Not sure whether a pricing issue is contracts, fee schedules, provider configuration, benefits, or adjudication?
Isolating the layer is most of the work. We test each one in turn and report where the behavior
actually originates.
What an operations engagement does not promise
- No guaranteed recovery amount, payment-accuracy rate, or financial outcome.
- No proprietary fee schedules, licensed code sets, or contractual reimbursement data supplied by us.
- No publication or exposure of payer-confidential reimbursement information.
- No replacement of contracted repricing networks, provider contracts, or third-party pricing services.
- Findings are engineering analysis of configuration and behavior, not an audit opinion or legal advice.
Solve it once, then make it a product capability
The point of this practice is not billable hours. Every operations engagement is also a search for the
repeatable pattern underneath a one-off problem — and repeatable patterns belong in software.
1 · Solve the immediate payer problem
Analyze the configuration, test the scenarios, validate the outcome, document the finding.
2 · Identify the repeatable pattern
The same question asked by a different plan, about a different fee schedule, on a different core.
3 · Automate the pattern in Cloud Health Office
Turn the manual analysis into product capability so the next plan does not pay for the same work.
Candidate capabilities identified this way — fee schedule version comparison, reimbursement
simulation, bulk claim replay, expected-versus-actual payment comparison, configurable pricing test
scenarios, claim explainability reports, regression test harnesses, provider contract test cases,
configuration impact analysis, pricing variance dashboards, reference-data validation, and audit evidence
generation — are tracked on the product roadmap. They are candidates under evaluation, not shipped
features, and none of them is a commitment.