SHPS, Inc.

What SHPS, Inc. does

SHPS, Inc. is a private US benefits-administration holding company headquartered in Louisville, Kentucky, with a 251–500 employee workforce and operations dating to 1997. Its principal operating subsidiary is Carewise Health, Inc. (founded 2003; "Carewise Health" / "CWH"), which was acquired in December 2013 by a small group of healthcare investors who also control Certilytics, Inc. and a health benefit consulting entity, creating an aligned group of synergistic businesses under common ownership.

Carewise Health delivers technology-enabled Clinical Care Management and Payment Integrity solutions to large health plans, provider health systems, self-insured employers (including Taft-Hartley unions), and government-funded programs. Clinical Care Management encompasses nurse-led utilization management, case management, disease management (URAC-accredited across nine disease states), maternity management, wellness coaching, and a 24/7 nurse line; Payment Integrity combines proprietary QEC predictive analytics with nurse auditor field work to identify and recover provider over-payments (claims of a 99% signed-audit success rate). Both product lines are supported by a Platform-as-a-Service data and analytics stack built on Microsoft, SQL Server, Oracle, and IBM foundations, with an exclusive Hadoop-based big-data layer provided by Certilytics, proprietary SACIE data-intake methodology, distributed computing and parallel processing, and a multi-client architecture delivering 360° participant risk profiling.

The business operates exclusively as B2B enterprise sales under multi-year, quote-based subscription contracts, with no consumer-facing pricing and no channel partners or resellers referenced. Revenue is generated through managed-services fees for clinical and payment-integrity engagements, percentage-of-recovery or fixed-fee payment-integrity contracts, standalone data services, and BPM professional services. Certifications (HITRUST CSF, HIPAA Business Associate, AICPA SOC 2, URAC) and a vendor security partnership with IBM (network intrusion) and McAfee (data-loss prevention) underpin enterprise and government buyer requirements. All data processing is conducted within the United States.

Name

SHPS, Inc.

Legal name

Carewise Health, Inc.

Website

https://carewisehealth.com

Company type

Private

Founded year

2003

Operating status

Operating

Headcount range

251–500 employees

Short description

SHPS, Inc., through its Carewise Health subsidiary, delivers technology-enabled clinical care management and payment integrity solutions to large US health plans, provider systems, self-insured employers, unions, and government entities via a proprietary PaaS analytics platform built on an exclusive Certilytics Hadoop partnership.

Ownership category

akta.pro rank

Product category

Healthcare Care Management

NAICS

Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292), Health and Welfare Funds (525120)

SIC

Services-Health Services (8000), Services-Misc Health & Allied Services, Nec (8090)

akta.pro industry

PRIMARYHLAEAEAJ

Managed Care Entity Administration for Medicaid (MCO/PHP/PIHP/PAHP)

Healthcare & Life Sciences/Health Insurance & Managed Care/Medicaid Managed Care (MMC) Plans

Keywords

• Clinical care management
• Payment integrity services
• Healthcare data analytics
• Care management platform
• Health plan solutions

Headquarters

HQ city

Louisville

HQ country

United States

HQ region

North America

Offices3 records

Markets served

GTM type

B2B

Offering type

Services

Cost components

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

Revenue model

1. Clinical Care Management Services: Technology-enabled care management delivered via nurse clinicians and coaches, including utilization management, case management, disease management, wellness, and maternity programs. Delivered as a managed service under multi-year enterprise contracts.
2. Payment Integrity Services: Pre- and post-payment cost reduction using nurse auditors and proprietary analytics to identify, audit, and recover health plan over-payments to providers. Revenue generated as a percentage of recovered amounts or as a fixed service fee under enterprise contracts.
3. Data Services (Standalone): Customers have the option to contract for the Data Services module (SACIE) independently of care management services, offering data intake, cleansing, enrichment, and warehousing as a standalone offering.
4. Business Process Management: Re-engineering of operational processes related to clinical programs using proprietary algorithms, models, and behavioral analytics developed jointly with Certilytics, Inc.

Pricing tiers

Go-to-market motion1 record

Distribution channels1 record

Marketing channels4 records

Core offering

SHPS, Inc., through its wholly-owned subsidiary Carewise Health, Inc., provides technology-enabled Clinical Care Management and Payment Integrity solutions delivered as a Platform-as-a-Service (PaaS) to health plans, provider health systems, self-insured employers, unions, and government entities. Its offerings combine proprietary predictive analytics, SACIE-based data management, and nurse clinician expertise to identify overpayments, support care coordination, and improve member health outcomes under multi-year enterprise contracts.

Product overview

Carewise Health, a wholly-owned subsidiary of SHPS, Inc., offers a unified platform-plus-modules architecture combining Clinical Care Management and Payment Integrity core products with data management services. The platform is delivered via a proprietary SaaS model (PaaS) where customers access technology without purchasing software. The core Clinical Care Management product includes sub-modules for Nurse Line, Wellness Programs, Disease Management, Case Management, Utilization Management, and Maternity Management. The Payment Integrity product features QEC Analytics for predictive case identification and nurse field audits. Data Management services include Data Intake and Enrichment (using the SACIE methodology), Data Warehousing, and Business Process Management—all powered by an exclusive Certilytics big data partnership. All services are supported by the multi-client Carewise Health Platform providing 360-degree participant views and risk profiling.

Differentiator

Problem solved

Functional benefit

Products and services

• Clinical Care Management A comprehensive suite of technology-enabled clinical and behavioral care management services including wellness, disease management, case management, utilization management, and maternity management programs delivered via nurse clinicians and telephonic support. Targeted at health plans, provider health systems, self-insured employers, and government entities.
• Payment Integrity A holistic payment integrity solution integrating technology, analytics, nurse auditors, and case managers to identify, audit, and recover health plan overpayments to providers through pre- and post-payment cost reduction strategies for health plans and government programs.
• Data Management and Analytics Proprietary data services including the SACIE (Security, Assembly, Cleansing, Integrity, Enrichment) approach for data intake, enrichment, warehousing, and advanced analytics powered by an exclusive Certilytics Hadoop-based big data platform partnership. Available as a standalone offering or integrated with care management.
• QEC (Quality, Efficacy, Cost) Analytics Proprietary predictive analytics engine using algorithms to identify cases for nurse audits or care management, create provider and member profiles, track high-risk providers, and build roadmaps to improved clinical and financial metrics, with a reported 99% success rate in obtaining signed audits from providers.
• Nurse Line 24/7 Health Advocacy 24/7 telephonic triage and health counseling service delivered by registered nurses certified in telephone triage, providing self-care instructions, care guidance, and navigation assistance for health plan members.
• Wellness Programs Personal wellness coaching and worksite wellness initiatives including nutrition, stress management, smoking cessation, weight management, and exercise programs delivered via telephone and onsite curriculum activities for self-insured employers and health plan members.
• Disease Management Telephonic disease management services using registered nurse specialists to help members with chronic conditions develop self-care skills, understand evidence-based practice guidelines, and manage their conditions long-term. URAC-accredited across nine core disease states.
• Case Management Coordinated care support services for members facing serious medical issues, with registered nurse specialists providing support, care coordination, and resource identification. URAC-accredited.
• Utilization Management Proactive procedures including pre-certification, concurrent review, discharge planning, and care coordination to ensure patients receive care at appropriate levels with the most effective treatment benefits.
• Maternity Management Maternity program providing expectant mothers with education on prenatal care, high-risk pregnancy management, postpartum support, and infant care guidance via registered nurse specialists.
• Carewise Health Platform Multi-client architecture platform hub integrating multiple data domains, organizing and delivering a 360-degree view of participants with risk profiling, workflow management, member portal, and integration framework supporting both clinical and payment integrity use cases.
• Data Intake and Enrichment Data cleansing and enrichment services that detect and correct errors, remove corrupt or duplicate records, verify completeness of critical content (member IDs, provider numbers, diagnosis and procedure codes), and prepare data for advanced analytics. Available standalone or bundled with other services.
• Data Warehousing Secure, stable data architecture supporting timely, accurate analysis and reporting with automated processes, distributed computing, parallel processing, and over 100M clinical experience data sets for predictive model development.
• Business Process Management Re-engineering of operational processes related to clinical programs using proprietary data assembly and analytic models jointly developed with Certilytics, incorporating behavioral profiling and process analytics.

Quantifiable outcome

• 99% success in obtaining signed audits from providers
• +1 more outcomes

Named customers4 records

Segments5 records

Ideal customer profiles4 records

Technology focussed No

API detail

Has API

No

API docs

API detail

Core technology

AI maturity

App detail

AI capability4 records

Feature8 records

Partnerships

Three partnerships are on record, tiered core and minor.

• Certilytics, Inc.coreTechnology or IntegrationCarewise Health holds an exclusive contract with Certilytics, Inc. to deploy proprietary data analytic models and a Hadoop-based 'big data' IT platform in support of Clinical Care Management and Payment Integrity product offerings. Certilytics' analytics are seamlessly integrated with Carewise Health applications. The two companies have also jointly developed proprietary algorithms and models for the BPM process. This is a long-standing strategic technology partnership central to Carewise Health's competitive differentiation.
• SHPS, Inc.coreOthersSHPS, Inc. is the parent company of Carewise Health. Carewise Health was formed as a subsidiary by SHPS in 2003 to develop health and wellness programs. In December 2013, Carewise Health was acquired by a small group of healthcare investors who also controlled Certilytics and health benefit consulting entities, creating a synergistic group of companies. Carewise Health remains a wholly-owned subsidiary of SHPS.
• BH ConsultingminorOthersBH Consulting serves as Carewise Health's designated EU Representative for GDPR inquiries from individuals located in the European Economic Area (EEA). Located at 30–31 Francis Street, Dublin 8, D08 N2C5, Ireland. Any GDPR rights requests are forwarded to the appropriate client (data controller) for response.

Scale indicators3 records

Recent moves8 records

Expansion highlights4 records

Broad incumbents

• Optum (UnitedHealth Group): Optum is the largest healthcare analytics, care management, and payment integrity platform in the US, serving health plans, employers, and government programs with a broadly similar solution suite. It is the dominant scaled incumbent against which Carewise Health competes in enterprise RFPs.
• Change Healthcare (now Optum): Change Healthcare offered payment accuracy, clinical decision support, and analytics solutions to health plans and providers, overlapping heavily with Carewise's payment integrity and clinical care management capabilities before its acquisition by Optum.
• MultiPlan: MultiPlan is a publicly traded healthcare cost management company providing payment integrity, network-based, and analytics-based solutions to health plans, payers, and employers — closely comparable to Carewise's enterprise buyer profile and product mix.
• IBM Watson Health (Truven): IBM Watson Health (including Truven Health Analytics) provides enterprise analytics, care management, and population health solutions to health plans and government — comparable in buyer profile and analytic depth to Carewise's platform.

Direct peers

• Cotiviti: Cotiviti provides payment integrity and risk adjustment analytics to health plans using proprietary algorithms and clinical expertise — a direct functional analogue to Carewise's Payment Integrity and QEC Analytics offerings.
• Zelis: Zelis provides healthcare cost management solutions including payment integrity, network management, and claims analytics to health plans and employers, directly competing with Carewise in payment integrity and analytics-driven cost containment.
• HMS Holdings (now Gainwell Technologies): HMS Holdings (acquired by Gainwell) provided payment integrity, population health, and care management services to Medicaid and commercial health plans and government agencies — directly overlapping Carewise's Medicaid managed care and government audit capabilities.
• SCIO Health (now emids): SCIO Health (acquired by emids) offered payment integrity, risk adjustment, and analytics services to health plans and providers — a near-direct comparable in scope, buyer base, and delivery model to Carewise Health.

Emerging players

• Health Catalyst: Health Catalyst provides data and analytics platform technology to health systems and health plans. While broader than Carewise's payment integrity focus, it competes for the same enterprise analytics and data warehousing budget that underpins Carewise's SACIE methodology.
• Clarify Health: Clarify Health provides analytics and value-based care navigation to health plans and providers using proprietary data assets — overlapping with Carewise's predictive risk profiling and care management analytics capabilities.

Market position

Strengths5 records

Weaknesses5 records

Competitive moat6 records

Key risks6 records

Key highlights7 records

Customer concentration

• Xx.com/carewisehealth
• LinkedInlinkedin.com/company/shps

Compliance4 records

Revenue estimate

Valuation estimate

Number of profiles

Profiles2 records

Funding overview

Funding rounds

Investors

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

M&A3 records

Investments

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

Frequently asked questions about SHPS, Inc.