Fraud Waste and Abuse Services
Medicaid programs provide valuable services to a state's citizens - but they are unfortunately targets for financial abuse and exploitation. We evaluate the integrity of payers and providers practices to ensure citizens receive the most value from their programs.
Solutions
Customized and Actionable
We partner with State Medicaid agencies to maintain program integrity and prevent payment of claims to providers with potentially fraudulent billing practices by examining claims prior to payment. We work to ensure that program dollars are not diverted, and that health and welfare of citizens is safeguarded.
- Clinical Claims Review
- Prepayment Claims Reviews
- Post-payment Reviews
- Claims on Review
- Targeted or Ad Hoc Reviews
- Special Investigative Unit (SIU) Services
- Program Integrity Consultation including Staff Augmentation
- Document Management, Extraction & Analysis Services
Outcomes
228M
TAX DOLLARS SAVED
$228M saved from going to fraud, waste or abuse during a 10-year investigative audit program with North Carolina
20%
20% REFERRAL RATE
More than 1 in 5 Medicaid Network providers we review are referred for potential program fraud or abuse or recipient abuse or exploitation. This work represents over 65 million dollars in Medicaid billings.
8:1
Return on Investment
8-to-1 ROI over a decade
Outcomes
228M
TAX DOLLARS SAVED
$228M saved from going to fraud, waste or abuse during a 10-year investigative audit program with North Carolina
20%
20% REFERRAL RATE
More than 1 in 5 Medicaid Network providers we review are referred for potential program fraud or abuse or recipient abuse or exploitation. This work represents over 65 million dollars in Medicaid billings.
8:1
Return on Investment
8-to-1 ROI over a decade
Customers
Decades of experience
We apply decades of experience understanding agency needs and healthcare realities working hand-in-hand with Program Integrity staff at State Medicaid agencies and other healthcare plans.