Payment Integrity Platform

PAYMENT INTEGRITY Case Study Scenarios With Potential Impacts Quick Links: Recover Missed Overpayments from Legacy Vendor Gaps SCENARIO: A regional health plan serving 1.2 million members seeks a more effective alternative after discovering inconsistent recoveries from its legacy payment integrity vendor. Potential Impact: Health plans may recover tens of millions in missed overpayments annually and […]

FRAUD DETECTION Over $1.6 Million in Billing Irregularities Discovered Challenge: Strengthening SIU Operations to Combat FWA CareSource, a leading managed care organization offering Medicaid, Medicare Advantage, and Marketplace plans, faced escalating challenges in detecting and preventing fraud, waste, and abuse (FWA) across its diverse lines of business. With rising healthcare costs and increasingly sophisticated fraudulent

FRAUD DETECTION AI-Powered Analytics Yields $50 Return for Every $1 Spent Challenge: Tackling Rising Costs and Fraud in Medicaid The Missouri Medicaid system, serving 1.3 million residents and processing over 100 million claims annually, faced mounting pressure to control costs and improve the detection of fraud, waste, and abuse (FWA). Medicaid spending in Missouri exceeded