Highlights of the Claims Integrity™ Fraud, Waste, and Abuse Solution Suite
- Industry-leading healthcare analytics powered by more than 2.5 billion medical events from clinical activity across more than 99% of U.S. counties – enabling unique matched-peer group analyses on a dynamic basis to identify meaningful signals of aberrancy indicating fraud, waste, and abuse.
- Multivariate signal variance insight into care activity standards across care delivery venue type, provider type, payor type, medical condition, diagnostic approach, intervention, geography, and time – providing claims integrity aberrancy signal detection capabilities that are not only advanced in their sophistication of analysis, but which also extend beyond the single-payor view.
- Seamless, secure, and HIPAA-compliant data transfer and integration, accommodating client data in their native formats, relieving the need for clients to maintain intensive IT resources.
- Comprehensive clinical, technical, CMS, state, and audit support aiding clients in all aspects of the challenging support, recapture and prevention process.
- Return-on-investment savvy solution focused on superior process support, threshold-driven financial impact results while minimizing clients’ internal staff resource requirements, remaining absent of hidden costs, and avoiding the need for voluminous costly support hours.
- Fully integrated EMR and paper-based medical record review, abstraction, and signal validation operations in all 50 states with hundreds of centralized data analysts, clinicians, review project managers, review schedule coordinators, and quality department personnel - combined with hundreds more in-field clinical review nurses, data collectors, and certified medical coders.
- Dedicated quality department consisting of hundreds of clinical nurse and certified coder employees dedicated to overseeing and supporting in-field employee training, medical record reviewer inter-rater reliability, quality compliance and overall project accuracy.
- Unmatched results transparency, substantiation, reporting, and progress tracking capabilities with extensive access to a broad array of rich reporting tools revealing not only cumulative and granular financial implication results, but also detailed insight into root causes and sources of fraud, waste, and abuse.
- Powerful analytics leveraging client datasets to expand beyond Claims Integrity™ fraud, waste, and abuse goals to deliver added value by providing powerful, synergistic integration with goals of risk adjustment, quality improvement, HEDIS® compliance, disease management, pay-for-performance, and granular business intelligence and insight.
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