Claims Integrity: A Medicare Fraud, Waste, and Abuse Solution

To identify instances of fraud, waste, and abuse, MedAssurant undertakes advanced analytics across member and provider activity incorporating comparisons to highly-specific peer-matched cohorts. Leveraging the data insight of billions of medical events, MedAssurant goes far beyond standard claims analytics, giving clients the benefit of sophisticated clinical analytics and standards of care considerations.

Ultimately, clients who may otherwise only have insight into a small window of encounter activity for any particular provider gain a more comprehensive and relevant picture of each caregiver. By partnering with MedAssurant, health plans can expect to reduce and recover unnecessary or inappropriate costs, improve efficacy of member care, support global regulatory fraud, waste, and abuse and strengthen the integrity of provider relations.

Identify and analyze potential instances of fraud, waste and abuse

MedAssurant’s solutions go far deeper than a simple analysis of administrative claims examining the practice patterns and any potential aberrations of individual practitioner’s clinical activities. Uniquely, MedAssurant seamlessly integrates a health plan’s member data and analyzes it based on a dynamic dataset of more than 4.5 billion medical events and sophisticated auto-adjusting clinical algorithms to reveal variations in practice patterns.  

Validate findings

Once aberrant practice patterns have been uncovered by clinical analytics, our field-based clinical review nurses, data collectors and certified medical coders use proprietary technologies to confirm findings through medical chart validation. The aggregated broader data attributes provide much more detailed insight into each provider’s practice patterns than achieved with a more traditional administrative claim review.

Inform through ongoing tracking and reporting

MedAssurant provides health plans unique insight. Throughout the engagement, MedAssurant provides customized analytics and reporting that is available 24/7 through a secure client-web portal to reveal process improvement and opportunities for immediate and ongoing improvements in financial performance.

Improve equality of member care and financial performance

MedAssurant’s Claims Integrity solutions successfully improve member care and reduce costs by identifying physicians practicing outside approved standards of care. We provide clients the insight they need to correct aberrant behavior and help providers implement or adhere to proven standards of care ultimately improving the integrity of the provider relationship.