fraud detection

reduce the costs of fraud, waste, and abuse

view the fact sheet

Multiple levels of proprietary analytics run on a variety of data sources to flag potentially bad billing behavior, which is then thoroughly reviewed by our clinical investigative unit (CIU). Our analytic-driven allegation referrals are then delivered to clients via a true production application, which our own CIU and the plan’s SIU use together to drill down into the data for greater detail. Allegation summaries provide a clear presentation of all facts, including suspect providers and their behavior, visualization to help conceptualize the findings, a list of patients associated with each allegation, and recommendations for further action. This reduces the amount of time that plan investigators spend on false positives by about 65%, leaving more time to investigate true cases and improving provider relationships.

Our optional case tracking tool is a comprehensive and highly customizable workflow management tool and information repository offered as an ASP solution, minimizing the SIU's administrative time and resources needed for complex investigative case tracking and reporting to law enforcement.

Clients may also select our optional SIU chart review services to augment their staff.

Results? Clients who self-report savings to us, per their process and accounting practices, report savings of between $0.40 and $1.70 PMPM*.
*Based on actual client results. Individual results will vary by client.

features

  • Highly customizable rules, data feeds and user experience
  • Predictive analytics, link-analysis and multi-variant models
  • Profiling and scoring of high-risk providers and fraud schemes
  • Clinical review and validation of all suspect billing activity
  • Fully vetted allegations sent directly to your SIU
  • Optional case tracking workflow tool and chart review services

benefits

  • Improve prevention and recoveries
  • Reduce the time and effort needed to validate fraud allegations
  • Reduce false-positive allegations and open more cases--we average an 85% case open rate with clients
  • Comply with state Medicaid program integrity requirements
  • Simplify complex case tracking
  • Lighten your staff's workload of fraud chart reviews

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