PayerFusion
PayerFusion Holdings is a Coral Gables-based third-party administrator providing health plan administration, cost containment, and medical case management to self-funded employers, international insurers, travel assistance companies, government programs, and NGOs via its claims management platform and global PayFuseNet provider network.
- Company typePrivate
- Founded2018
- HeadquartersMiami, United States
- Headcount11–50
- GTM typeB2B
- OfferingServices
What PayerFusion does
PayerFusion Holdings, LLC is a privately held third-party administrator (TPA) headquartered in Coral Gables, Florida, that delivers complete health plan administration, cost containment, and medical case management services to self-funded employers, international insurers, travel assistance companies, government programs, and NGOs. The company was founded in 2018 and operates with 11-50 employees under CEO Griselle Chernys. Its core product is a HIPAA-compliant, web-enabled Claims Management Software that adjudicates multi-currency, multi-language claims with 128-bit SSL encryption, role-based security, and open interfaces for legacy system integration.
The technology stack is anchored by two proprietary assets: a cost-plus pricing methodology that prices claims against the actual cost of appropriate care rather than percentage discounts off inflated retail prices, and the PayFuseNet provider network spanning the USA, Puerto Rico, the Caribbean, Latin America, Europe, Asia, New Zealand, and South Africa, with networks in development in Egypt, Turkey, India, and China. Add-on modules include medical case management, repricing and adjudication, and specialty networks for dental, pharmacy (45% average savings, powered by EHIM with 62,000+ pharmacies), and vision (12,000 providers). Specialty services such as Second Medical Opinion, White Glove Service, Medical Escort, and House Calls differentiate the offering for international and expatriate members.
PayerFusion's revenue model combines recurring TPA fees on multi-year enterprise contracts, transaction-based cost containment fees, network access fees, and licensing/royalty revenue from international insurance products distributed through its WellAway Limited partnership (covering ACA-compliant expatriate plans, student plans, and customized group coverage). Distribution runs through direct enterprise sales to self-funded employers and insurers, the WellAway brokerage channel for international products, and provider enrollment into the PayFuseNet network. Certifications include HIPAA compliance, ISO standards adherence, Six Sigma protocols, and Charles Taylor London Market Expert accreditation.
PayerFusion firmographics
Firmographics- Name
- PayerFusion
- Legal name
- PayerFusion Holdings, LLC
- Website
- https://payerfusion.com
- Company type
- Private
- Founded year
- 2018
- Operating status
- Operating
- Headcount range
- 11–50 employees
- Short description
- PayerFusion Holdings is a Coral Gables-based third-party administrator providing health plan administration, cost containment, and medical case management to self-funded employers, international insurers, travel assistance companies, government programs, and NGOs via its claims management platform and global PayFuseNet provider network.
- Ownership category
- akta.pro rank
PayerFusion industry classification
Industry- Product category
- Healthcare Third-Party Administration
- NAICS
- Pharmacy Benefit Management and Other Third Party Administration of Insurance and Pension Funds (524292)
- SIC
- Hospital & Medical Service Plans (6324), Insurance Agents, Brokers & Service (6411)
- akta.pro primary industry
- Self-Funded Employer Plan TPA (ASO Administration) (HLAEALAA)
- akta.pro secondary industry
- Dental & Vision Third-Party Administration (TPA) (FSAIAHAL)
Keywords
Where PayerFusion is headquartered
LocationHeadquarters
- HQ city
- Miami
- HQ country
- United States
- HQ region
- North America
Offices3 records
Markets served
PayerFusion business model
Business model- GTM type
- B2B
- Offering type
- Services
- Cost components
- Personnel, Operations, Technology or R&D, Marketing or Sales, Infrastructure, Supply Chain
Revenue model
- Third-Party Administration (TPA) Fees: PayerFusion charges fees for comprehensive health plan administration services including claims processing, medical case management, cost containment, and policy administration for self-funded employers, international insurers, and travel assistance companies.
- Cost Containment Services: Revenue generated through the company's proprietary cost-plus pricing methodology and claims analysis services that produce savings for clients, with fees likely tied to achieved savings or as a percentage of reduced claim costs.
- WellAway International Insurance Products: In partnership with WellAway Limited, PayerFusion powers international health insurance plans including expatriate ACA/Obamacare compliant plans, student plans, and customized group health coverage, providing agency and brokerage services for insurance distribution.
- Network Access & Provider Services: Revenue from providing access to the PayFuseNet provider network including dental, pharmacy, and vision networks. Clients pay for network access and discounted rates on healthcare services.
- Medical Case Management Services: Fees for coordinating medical care for pre-planned procedures, monitoring treatment, directing patients to in-network providers, and facilitating hospital admissions and appointments.
Pricing tiers
| Model | Billing | Price |
|---|---|---|
| Other | Multi-year contract | Custom enterprise pricing for self-funded employers and insurers |
Go-to-market motion2 records
Distribution channels5 records
Marketing channels7 records
PayerFusion product offering
Product offeringCore offering
PayerFusion is a healthcare third-party administrator (TPA) that delivers complete health plan administration solutions for self-funded employers, international insurers, travel assistance companies, and government programs. Its core offering combines proprietary claims management software, a Cost-Plus pricing methodology that reimburses based on actual cost of care, and the PayFuseNet global provider network to deliver claims processing, cost containment, medical case management, and specialty services. The company achieves documented claim charge reductions of 35% to 94% for clients across international and domestic markets.
Product overview
PayerFusion offers a unified health plan administration platform built around its Claims Management Software (TPA Software) as the core product, supported by the proprietary PayFuseNet provider network. The Cost-Plus Methodology serves as the foundational pricing approach across all services. Add-on modules include Medical Case Management, Medical Claims Management, and specialty networks for dental, pharmacy, and vision services. Specialty Services provide differentiated care coordination including Second Medical Opinion, White Glove Service, Medical Escort, and House Calls. The WellAway sub-brand extends international health insurance products for expatriates. The architecture integrates these components to deliver complete health plan administration solutions for self-funded employers, international insurers, and travel assistance companies.
Differentiator
Problem solved
Functional benefit
Brands
- PayFuseNet: Proprietary provider network providing access to maximum savings and high-quality healthcare providers, featuring Zero-Balance Billing Guarantee. Network established across USA, Puerto Rico, Caribbean, Latin America, Europe, Asia, New Zealand, and South Africa.
- WellAway
Products and services
- Claims Management Software Enterprise-class web-based claims processing and policy administration platform that analyzes millions of claim transactions, generates reports and informatics, enables fraud detection, and provides predictive modeling for cost projections. Designed for health plans administered on behalf of self-funded employers, international insurers, and travel assistance companies.
- PayFuseNet Provider Network Proprietary provider network offering open access to quality healthcare providers with zero-balance billing guarantee, supporting cost-plus reimbursement methodology without network membership requirements. Spans the USA, Puerto Rico, Caribbean, Latin America, Europe, Asia, New Zealand, and South Africa.
- Cost-Plus Methodology Proprietary medical claims pricing methodology that bases reimbursement on actual cost of care rather than percentage discounts off inflated retail prices, leveraging real cost and quality data mined with a unique algorithm.
- Medical Case Management Coordination service for pre-planned procedures and ongoing medical treatment that ensures patients receive appropriate care while promoting cost savings through evidence-based medicine and best practice guidelines.
- Medical Claims Management Full-service medical claim processing including repricing, adjudication, analysis, validation, and customized reporting with multi-currency support and episode life cycle management.
- PayFuseNet Dental Network Reduced-fee dental program providing access to independent contractors in private practice who have agreed to contracted rates as payment in full, with specialists offering discounts according to individual fee schedules.
- PayFuseNet Pharmacy Network Extensive pharmacy network offering significant savings with customized coverage and member services including PBM services, discount cards, and mail-in pharmacy options with 45% average savings to clients.
- PayFuseNet Vision Network Network of 12,000 vision service providers including ophthalmologists, optometrists, and optical centers with early morning, evening, weekend appointments and a 30-day money-back guarantee.
- Second Medical Opinion Access to expert opinions from world-renowned doctors at internationally recognized Centers of Excellence, including formal written evaluations, telemedicine consultations, and facility admission assistance.
- White Glove Service VIP coordination service for patients traveling to the US for care, providing personalized written instructions, dedicated Service Account Managers, and on-site Service Managers for logistics and medical care coordination.
- Medical Escort Service Cost-effective alternative to air ambulance transport providing registered nurse escorts for patients traveling on commercial airlines after surgeries, accidents, or illness, including mobility assistance and vital signs monitoring.
- House Call Service High-quality medical care delivered to homes, hotel rooms, or offices by board-certified physicians for patients who cannot or prefer not to travel to doctor's offices.
- WellAway International Health Insurance International health insurance products for expatriates and families, groups, government programs, and NGOs offered in partnership with WellAway Limited, including ACA/Obamacare compliant plans for foreign students and temporary workers.
Quantifiable outcome
- Achieved up to 94% reduction in medical charges through cost containment methodology (documented case: $400K acute stroke case reduced to savings of $376,000)
- +6 more outcomes
Companies that use PayerFusion
Customer profileNamed customers4 records
Segments6 records
Ideal customer profiles3 records
PayerFusion technology and API
TechnologyTechnology focussed Yes
API detail
- Has API
- No
- API docs
- API detail
Core technology
AI maturity
App detail
Integration4 records
AI capability4 records
Feature8 records
PayerFusion partnerships and signals
Strategic signalPartnerships
Two partnerships are on record, tiered core.
- WellAway LimitedcorePayerFusion partners with WellAway Limited, an international insurer and brokerage company, to provide international health products tailored for expatriates and their families, groups, government programs, NGOs, and more. WellAway offers routine healthcare, hospitalization, prescription medication, evacuation and repatriation, plus options such as vision and dental. WellAway is the first international insurer approved to provide ACA/Obamacare compliant health plans, featuring the power, stability, and technology of a TPA combined with the care of a respected international insurer. PayerFusion powers WellAway's products including international health insurance plans, ACA-compliant plans for expatriates and foreign students, student plans meeting visa requirements, and customized group health coverage.
- Charles Taylor (London Market Experts)corePayerFusion is accredited as one of Charles Taylor's London Market Experts, recognizing the company's expertise and standing within the London insurance market as a third-party administrator. This accreditation supports PayerFusion's credibility with international insurers operating in the London market.
Scale indicators6 records
Recent moves6 records
Expansion highlights5 records
PayerFusion competitors and assessment
Company assessmentDirect peers
- MultiPlan: MultiPlan is one of the largest US TPAs and cost-containment networks for self-funded employer plans, offering PPO-style discount networks, claim repricing, and payment-integrity services — directly overlapping PayerFusion's TPA and cost-containment core offering.
- Zelis: Zelis provides healthcare cost management, claims integrity, network solutions, and payment accuracy services to health plans, TPAs, and self-funded employers — a closely aligned peer in claims repricing, cost containment, and provider network access.
- Global Excel Management: Global Excel Management is a cost-containment and medical assistance company serving international insurers, travel assistance firms, and self-funded plans — a comparable peer given PayerFusion's international claims, cost containment, and expatriate focus.
- Imagine360: Imagine360 is a TPA offering claims administration, cost containment, provider networks, and stop-loss support to self-funded employers — directly comparable to PayerFusion's self-funded program administration and cost-plus repricing services.
- HealthSCOPE Benefits: HealthSCOPE Benefits is a third-party administrator providing claims processing, network management, and cost-containment solutions for self-funded employer health plans — a closely matched peer in the US self-funded TPA segment.
Broad incumbents
- Optum: Optum (UnitedHealth Group) is a broad incumbent across health-services operations including claims administration, PBM, provider networks, and analytics — overlapping with PayerFusion across multiple service lines but at vastly greater scale and with a much broader portfolio.
- Change Healthcare (Optum): Change Healthcare, now part of Optum, provides revenue cycle management, claims processing, and payment-integrity solutions to payers and providers — overlapping with PayerFusion's claims management, repricing, and analytics capabilities as part of a much broader enterprise platform.
- Cigna Healthcare (Evernorth): Evernorth (Cigna Group) offers PBM, specialty pharmacy, and health-services solutions including claims administration and care management — a broad incumbent that competes with PayerFusion for self-funded employer and international insurer business as part of an integrated portfolio.
Market position
Strengths5 records
Weaknesses5 records
Competitive moat5 records
Key risks6 records
Key highlights7 records
Customer concentration
PayerFusion social profiles
Digital presencePayerFusion compliance and trust
Trust signalCompliance4 records
PayerFusion financial estimates
Financial estimateRevenue estimate
Valuation estimate
PayerFusion leadership team
Management profileNumber of profiles
Profiles1 record
PayerFusion subsidiaries and ownership
Company hierarchySubsidiaries1 record
PayerFusion funding detail
Funding detailFunding overview
Funding rounds
Investors
Funding detail is available on the Subscription and Enterprise plan.Contact sales →
PayerFusion M&A and investment
M&A and investmentM&A
Investments
M&A and investment is available on the Subscription and Enterprise plan.Contact sales →
Frequently asked questions about PayerFusion
What does PayerFusion do?
PayerFusion is a healthcare third-party administrator (TPA) that delivers complete health plan administration solutions for self-funded employers, international insurers, travel assistance companies, and government programs. Its core offering combines proprietary claims management software, a Cost-Plus pricing methodology that reimburses based on actual cost of care, and the PayFuseNet global provider network to deliver claims processing, cost containment, medical case management, and specialty services. The company achieves documented claim charge reductions of 35% to 94% for clients across international and domestic markets.
Is PayerFusion a public or private company?
PayerFusion is a private company. It is classified as founder individual operated bootstrapped and is currently operating.
When was PayerFusion founded?
PayerFusion was founded in 2018. It employs 11 to 50 people.
Where is PayerFusion based?
PayerFusion is headquartered in Miami, United States, in the North America region.
How does PayerFusion make money?
Five revenue lines are on record. Third-Party Administration (TPA) Fees are the primary driver. The others are cost Containment Services, wellAway International Insurance Products, network Access & Provider Services and medical Case Management Services.
Who are PayerFusion's main competitors?
Direct peers on record are MultiPlan, Zelis, Global Excel Management, Imagine360 and HealthSCOPE Benefits. Broad incumbents are Optum, Change Healthcare (Optum) and Cigna Healthcare (Evernorth).
Does PayerFusion have an API?
No public API is recorded for PayerFusion.
What industry is PayerFusion in?
PayerFusion's product category is Healthcare Third-Party Administration. Its primary akta.pro industry code is HLAEALAA, Self-Funded Employer Plan TPA (ASO Administration), with a secondary code of FSAIAHAL, Dental & Vision Third-Party Administration (TPA). Its NAICS code is 524292 and its SIC code is 6324.