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We’ve been able to design a daily workflow in our SIU that helps us spot potential fraud before we process a claim and also allows the SIU to identify and recoup claims that were paid to sanctioned or excluded providers.

Jowanna W., Program Integrity Analyst – Special Investigations Unit

It’s time to reduce the costs of claims overpayment and recovery.

Claims overpayment and recovery is a health insurance epidemic.

Overpaying claims and trying to recoup later is inefficient.

Between $68 and $226 billion is lost annually to Fraud, Waste and Abuse (FWA). We partner with health plans across the U.S. to implement smarter, predictive provider network monitoring to spot claims from ineligible providers before they are paid.

Claims recovery efforts are costly.

Traditional methods of claims recovery can quickly escalate the cost of the claim. Our primary source data monitoring and matching algorithms spot potential FWA faster and deliver the documentation and evidence you need, saving your Special Investigations Unit time and money.

Connecting pre-pay screening with post-pay monitoring is complex.

Pre-pay analytics and FWA screening are traditionally disconnected from ongoing provider monitoring and continuous credentialing. We monitor your entire provider network and connect every provider’s eligibility status in real-time with your claims processing system, helping ensure payment integrity.

Disparate provider data systems create blindspots.

Data silos across credentialing, claims, provider data management systems creates toil for SIU teams across health plans. We help health plans ensure a source of truth for accurate, monitored provider directories and integrate with the systems across your plan to ensure consistency.    

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Smarter monitoring leads to improved compliance and fewer claims to chase.

Continuous provider monitoring and claims integration ensure you spot FWA as quickly as possible.

Our matching algorithms spot Medicare/Medicaid exclusions no one else can.

Integrate smarter provider data into your claims processing workflow for real-time results.

Top Seven Monitoring Challenges for Health Plans

Smart, integrated monitoring is the key to mitigating risk within provider networks. As health plans transition to ongoing eligibility monitoring, these are the top challenges they face.

Resources to help Payment Integrity teams grow & succeed.

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It’s time to simplify payment integrity.