The Intelligence Engine
The EPIQ Intelligence Engine. Under the hood.
Forensic pharmacy visibility, catastrophic risk stratification, and ER redirection — the deeper capabilities of the EPIQ analytics stack. Predictive, not rear-view.
Specialty Rx Cost Splitting
Traditional pharmacy reports only capture what is visible on the pharmacy benefit. They completely miss high-cost specialty drugs billed as J-Codes under the medical benefit — masking the true cost of oncology infusions, Humira, Mounjaro, and other physician-administered therapies.
Forensic pharmacy visibility
Our tools reconcile medical and pharmacy claims to expose the full Rx picture — including hidden specialty spend that brokers never surface.
Target expensive therapies at the source
Once identified, we deploy active clinical management guidelines and prior authorization strategies to reduce unit cost and steer toward clinically appropriate alternatives.
Proof Point · Pharmacy Liability
Rx-only benefit capture
Includes medical-benefit J-Codes & specialty infusions
Traditional brokers miscalculate your Rx liability at 21% of your plan spend. Our forensic tools reveal that Medically Administered Rx actually drives pharmacy to 30% of total plan costs — allowing us to target expensive specialty drugs like Mounjaro, Humira, and oncology infusions at the clinical source.
Proof Point · Catastrophic Risk
1%
of the workforce
36%
of total healthcare spend
We utilize active clinical management guidelines to lower high-cost claimant prevalence across focus conditions, shifting spend from catastrophic reactive care to proactive, evidence-based intervention.
The 1% Risk Rule: Forensic Stratification
Most plans treat all members equally. We treat them precisely. Our modeling shows that the Top 1% of your workforce typically drives 36% of your total healthcare spend. Ignoring this concentration is the single fastest way to destroy a renewal budget.
Cardiac Disorders
Early identification of congestive heart failure, coronary artery disease, and post-event readmission risk through predictive flags and care coordination.
Diabetes & Metabolic Syndrome
Targeting uncontrolled Type 2 diabetes, insulin dependency, and comorbid obesity before they trigger ER visits, amputations, or dialysis-level spending.
Hypertension & Chronic Kidney Disease
Closing the gap between diagnosis and control. We flag declining eGFR trends and rising BP readings to prevent progression to stage-4/5 CKD and transplant eligibility.
ER Optimization & Redirection
Emergency room visits are the single most expensive entry point into the healthcare system — and a significant share are entirely avoidable. We use forensic claims auditing to identify steerable ER utilization and redirect members to appropriate primary care, telemedicine, and urgent care alternatives.
Forensic utilization review
Our analytics flag avoidable ER episodes by diagnosis, time of day, and member history — giving us a clear map of where redirection will produce the highest return.
Active steering & alternative care networks
We deploy telemedicine, nurse-line triage, and same-day primary care access to intercept non-emergency episodes before they hit the ER — cutting the paid claim by over 90% per event.
Proof Point · Redirect Math
Forensic auditing identified that 15% of this population's ER usage was entirely avoidable. By using our primary care and telemedicine steering models, every single ER redirection to alternative care centers saved the plan an average of $774 per event.
Privacy & Security. All analytics are performed on de-identified data in 100% compliance with HIPAA regulations. We use institutional-grade AI to protect your employees' privacy while protecting your company's margins.
Ready to see these signals against your own plan?
See how your plan compares to our 20-million-member national benchmark database. No pitch decks. Just hard financial data.