Key Features
- Real-Time Provider Risk Scoring: Uses AI-driven analytics, historical claims data, and regulatory benchmarks to flag high-risk providers before payment.
- Configurable Edits & Triggers: Applies payer-defined logic to pend or deny claims prior to adjudication, ensuring flexibility and alignment with CMS, OIG, and Medicaid guidelines.
- SIU Workflow Integration: Seamlessly routes flagged claims into SIU case management for focused review and faster investigations.
- Pre-Adjudication Focus: Enables earlier intervention to stop improper payments before they occur.
- Regulatory Compliance & Audit Support: Maintains a clear audit trail to support dispute resolution, legal defense, and compliance with evolving federal and state oversight requirements.
- Scalable Deployment: Adapts across commercial, Medicare, and Medicaid lines of business, supporting plans of all sizes.
ONE PLATFORM for FWA powers earlier action—stopping high-risk providers at the source and sharing insights across the claims lifecycle.
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Knowledge Bank:
What is FWA Claims Manager™?
FWA Claims Manager™ is an AI-driven, pre-payment fraud analytics tool built to detect and stop suspicious healthcare providers before claims are paid. It enhances fraud, waste, and abuse (FWA) prevention by analyzing patterns in real-time and integrating seamlessly with existing claims platforms.
Key Features
- Real-Time Provider Risk Scoring:
Uses machine learning and historical claims data to assess provider risk at the point of claim submission. - Customizable Claim Triggers:
Suspends or flags claims for further review based on indicators like excessive utilization, high dollar amounts, or policy violations. - Built-in Compliance & Audit Trail:
Facilitates compliance with CMS, OIG, and state-level regulations while maintaining a secure and transparent audit log for every decision. - Advanced Integration Capabilities:
FWA Claims Manager™ is designed to integrate with industry-standard claims systems used by health plans and Medicaid agencies, ensuring fast deployment and minimal disruption.
Supported Claims Systems
- AMISYS – A core healthcare management platform widely used by payers for eligibility, claims, and benefits management.
- Conduent HSP™ – Modernized Medicaid and state health enterprise systems with configurable modules.
- HealthEdge™ / HealthRules™ – A real-time claims and benefit administration platform designed for value-based care.
- PowerMHS™ & PowerSTEPP™ – Conduent solutions for Medicaid Management Information Systems (MMIS) and encounter processing.
- TriZetto QNXT™ – Comprehensive claims processing and care management solution for government and commercial payers.
- TriZetto Facets™ – Scalable core administrative processing system for large health plans and BCBS organizations.
Frequently Asked Questions (FAQ)
What claims systems are compatible with FWA Claims Manager™?
FWA Claims Manager™ integrates with several industry-standard claims platforms, including AMISYS, Conduent HSP™, HealthEdge™ / HealthRules™, PowerMHS™ & PowerSTEPP™, TriZetto QNXT™, and TriZetto Facets™. These integrations allow payers to implement fraud prevention quickly without disrupting existing operations.
Can the FWA Claims Manager™ detect fraud before payment is made?
Yes. The solution is designed specifically for pre-payment fraud detection, allowing payers to intervene before financial loss occurs by flagging high-risk claims and providers in real-time.
How does FWA Claims Manager™ determine provider risk?
The tool applies machine learning and AI to historical and real-time claims data. It calculates a provider risk score based on abnormal billing patterns, excessive claim frequency, and violations of established policies or industry benchmarks.
Does FWA Claims Manager™ support compliance and audit readiness?
Absolutely. It maintains a detailed audit trail for each flagged claim and decision, supporting compliance with CMS, OIG, and state-level regulations. It also simplifies documentation during disputes or audits.
How does integration work with our current system?
FWA Claims Manager™ offers modular and API-based integration, ensuring it complements rather than replaces your current claims processing workflows. Its support for widely used systems ensures rapid deployment and minimal IT overhead.
