MedReview

What MedReview does

MedReview (legal entity NYCHSRO/MedReview, Inc.) is a physician-led payment integrity company founded circa 1970 and headquartered in New York City. The firm sells clinical and coding review services to U.S. health plans, government agencies (Medicaid Managed Care, MLTC), payers, and Taft-Hartley organizations, delivered through both prepay and postpay engagements with multi-year enterprise contracts.

The core product suite spans Payment Integrity (DRG coding reviews, clinical validation by board-certified physicians, hospital bill audits, readmission reviews, cost outlier audits, and data mining) and Quality Management (HEDIS/QARR abstractions, Medicaid Managed Care assessments, and independent review for government agencies). Underpinning these services is a Human-in-the-Loop AI architecture that combines proprietary claim-analysis algorithms and 400+ tailored data-mining concepts with mandatory physician adjudication of every reassignment; the company reports less than a 5% appeal overturn rate and average savings of $3,500 per claim. In March 2026 MedReview acquired Vital Data Technology, adding the Affinitē AI-driven payer analytics platform (care management, quality, population health, risk adjustment) as a wholly-owned subsidiary.

MedReview earns revenue primarily through professional-service fees structured as a share of recovered savings and per-claim pricing on a quote-based, multi-year enterprise basis. Distribution is entirely direct: field sales, inside sales, regional business-development leads, and conference presence at NHCAA, HPRI, AHIP, CAHP, WAHP, and NYHPA. HITRUST r2 Certification and Authorized External Assessor designation support the regulatory moat and access to government health-program work.

Name

MedReview

Legal name

NYCHSRO/MedReview, Inc.

Website

https://medreview.us

Company type

Private

Founded year

1970

Operating status

Operating

Headcount range

101–250 employees

Short description

MedReview is a physician-led payment integrity provider founded in 1970 serving U.S. health plans, government agencies, payers, and Taft-Hartley organizations with clinical validation, DRG coding reviews, hospital bill audits, and AI-driven data mining delivered via a Human-in-the-Loop model.

Ownership category

akta.pro rank

Product category

Healthcare Payment Integrity

SIC

Hospital & Medical Service Plans (6324)

akta.pro primary industry

Medigap Fraud, Waste & Abuse (FWA) & Payment Integrity (HLAEADAI)

Keywords

• Healthcare Payment Integrity
• DRG Coding Reviews
• Clinical Validation
• Hospital Bill Audits
• Claims Data Mining

Headquarters

HQ city

New York

HQ country

United States

HQ region

North America

Offices3 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure, Others

Revenue model

1. Payment Integrity Services: MedReview provides a comprehensive suite of payment integrity solutions including DRG coding reviews, clinical validation reviews, hospital bill audits, readmission reviews, cost outlier audits, and data mining services. Services are delivered as either prepay or postpay solutions, with flexible configurations to meet client needs. Revenue is generated through service fees based on claims reviewed and savings identified for clients, typically structured as a percentage of recovered savings or per-claim pricing.

Pricing tiers

Go-to-market motion2 records

Distribution channels3 records

Marketing channels6 records

Core offering

MedReview provides healthcare payment integrity and quality management services to health plans, government agencies, and Taft-Hartley organizations. The company performs DRG coding reviews, clinical validation, hospital bill audits, readmission reviews, HEDIS/QARR reviews, and independent reviews, combining proprietary AI-driven algorithms with physician-led human-in-the-loop oversight to reduce improper payments and improve care quality.

Product overview

MedReview is a physician-led payment integrity platform offering a comprehensive suite of solutions for health plans, government agencies, and payers. The core portfolio includes Payment Integrity (pre-pay and post-pay DRG coding reviews, clinical validation, hospital bill audits, readmission reviews) and Quality Management (HEDIS/QARR reviews, independent review, Medicaid managed care assessments). In March 2026, MedReview acquired Vital Data Technology, adding the Affinitē AI-driven analytics platform for predictive insights in care management, quality, population health, and risk adjustment. The platform combines clinical expertise from board-certified physicians with advanced algorithms and data mining to identify waste, fraud, and abuse in healthcare claims.

Differentiator

Problem solved

Functional benefit

Products and services

• Payment Integrity Comprehensive payment integrity solution combining DRG coding reviews, clinical validation, hospital bill audits, and data mining to detect and prevent improper claims payments for healthcare payers.
• DRG Coding Reviews Diagnosis-Related Group coding reviews performed by certified coders and physicians to validate accuracy of inpatient claims and ensure appropriate reimbursement levels.
• Clinical Validation Physician-led clinical validation of diagnoses and procedures on claims to ensure documentation supports the billed services and meets medical necessity criteria.
• Hospital Bill Audits Detailed line-item audits of hospital claims to identify billing errors, duplicate charges, and non-covered services, recovering overpayments for payers.
• Data Mining Proprietary algorithms that analyze claims data to identify aberrant billing patterns, high-risk providers, and potential improper payments across large claim populations.
• Readmission Reviews Clinical reviews to identify potentially preventable hospital readmissions, supporting value-based care and quality improvement initiatives.
• Quality Management Quality management services including HEDIS/QARR reviews, independent reviews, and Medicaid Managed Care Assessments to support regulatory compliance and quality ratings.
• HEDIS/QARR Reviews Healthcare Effectiveness Data and Information Set (HEDIS) and Quality Assurance Reporting Requirements (QARR) reviews to support quality measurement and reporting for health plans.
• Independent Review Independent physician reviews of disputed or contested claims to provide objective clinical determinations for payers.
• Medicaid Managed Care Assessments Assessments to support Medicaid managed care programs in evaluating provider performance, quality of care, and compliance with program requirements.
• Affinitē Unified AI-powered platform for value-based care, population health management, and clinical intelligence, acquired from Vital Data Technology in March 2026 to extend MedReview's quality and care management capabilities.
• Physician and Advisory Services Physician advisory services providing clinical expertise, medical director support, and consultation for payers on complex claims determinations and care management.

Quantifiable outcome

• Total savings of more than $3 billion for payer clients; $351 million saved in 2022 alone
• +6 more outcomes

Named customers4 records

Segments4 records

Ideal customer profiles3 records

Technology focussed Yes

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

AI capability7 records

Feature4 records

Partnerships

Two partnerships are on record, tiered core and minor.

• Vital Data TechnologycoreStrategic or Co-development Partner · 31 March 2026MedReview acquired Vital Data Technology, the premier provider of advanced healthcare payer workflow and data technology. Founded in 2005, Vital Data Technology empowers the healthcare ecosystem with predictive insights through its AI-driven intelligent analytics platform called Affinitē. The acquisition strengthens and expands MedReview's comprehensive payer solution suite by adding member outcome-focused solutions. Vital Data will operate as a wholly-owned subsidiary of MedReview.
• CUNY School of Professional Studies (CUNY SPS)minorStrategic or Co-development Partner · 25 April 2024MedReview and its parent company NYCHSRO launched the NYCHSRO Medical Coding Scholarship Fund in partnership with CUNY SPS. The scholarship supports approximately 20 students enrolled in the Medical Coding certificate program at CUNY School of Professional Studies starting Fall 2024, chosen based on academic excellence. The scholarship provides $1,000 toward first-semester tuition, exam fee coverage for CCA and CCS certifications, and tuition coverage for the last four courses. The partnership also offers internship opportunities, curriculum development focused on auditing, and potential employment prospects for graduates.

Scale indicators8 records

Recent moves6 records

Expansion highlights5 records

Direct peers

• Cotiviti: Cotiviti is a leading healthcare payment integrity and analytics vendor offering DRG validation, clinical claim review, and data mining to health plans. It is one of MedReview's most direct competitors and shares payer-side customers and overlapping leadership pedigrees.
• Gainwell Technologies: Gainwell Technologies (formerly HMS) provides payment integrity, fraud detection, and coordination of benefits services to government and commercial payers. It directly overlaps MedReview's DRG validation, clinical review, and Medicaid managed care offerings.
• Discovery Health Partners: Discovery Health Partners specializes in payment integrity including subrogation, coordination of benefits, and clinical claim review for health plans. It is a direct competitor with comparable services and similar customer segment focus.
• MultiPlan: MultiPlan provides cost containment, payment integrity, and claim review services to payers and self-funded employers. It is comparable to MedReview in delivering prepay and postpay savings on complex claims across DRG and clinical validation categories.
• Conifer Health Solutions: Conifer Health Solutions offers revenue cycle management and payment integrity services to hospitals, health systems, and payers. Its clinical denial management and claim review capabilities overlap directly with MedReview's payment integrity portfolio.

Broad incumbents

• Optum (UnitedHealth Group): Optum operates the largest integrated payment integrity, claims processing, and clinical review operation in the U.S. as part of UnitedHealth Group. It competes with MedReview across payer and government markets while also serving as a potential acquirer of adjacent capability.

Emerging players

• Codoxo: Codoxo is an AI-first payment integrity vendor using machine learning for claim review, fraud detection, and provider payment accuracy. It competes with MedReview through a more automated cost structure targeting similar payer customers.
• Machinify: Machinify applies AI and large language models to payment integrity and utilization management for health plans. It is an emerging AI-native competitor to MedReview's physician-led clinical validation model, focused on similar payer customers.
• Clarify Health: Clarify Health provides AI-driven healthcare analytics for payers and providers, including payment integrity, network design, and value-based care insights. It is comparable to MedReview's expanded Affinitē-enabled analytics ambitions.

Others

• Edifecs: Edifecs provides healthcare data interoperability, payment accuracy, and value-based care technology. While not a direct payment integrity competitor, it operates in adjacent payer-side data exchange and compliance categories that intersect with MedReview's footprint.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat5 records

Key risks6 records

Key highlights7 records

Customer concentration

• LinkedInlinkedin.com/company/nychsro-medreview
• Xx.com/MedReviewInc

Compliance3 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles18 records

Subsidiaries1 record

Funding overview

Funding rounds

Investors

Funding detail is available on the Subscription and Enterprise plan.Contact sales →

M&A1 record

Investments

M&A and investment is available on the Subscription and Enterprise plan.Contact sales →

Frequently asked questions about MedReview