Fraud, Waste & Abuse System

Catch improper claims before payment — and recover what slipped through

Rule-based pre-payment review, paid-claim analytics and tracked investigations, tuned to your plan's own policies rather than a generic edit library.

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How the programme runs

Detection, analysis and case work operate as one loop, so each finding sharpens the rules applied to the next claim.

Pre-Payment Claim Review

Suspect claims are flagged before payment goes out, using rule sets tuned to your plan's policies and history.

Rules for unbundling, upcoding, duplicate and impossible-day billing
Provider and member outlier detection against peer patterns
Configurable thresholds so review volume matches your team's capacity
Flagged claims routed to a review queue with the supporting evidence

Post-Payment Analytics

Paid-claim analysis that surfaces patterns a single-claim edit will never catch.

Trend analysis by provider, procedure, member and geography
Overpayment identification with recovery worklists
Ranked findings by recoverable dollars and confidence
Feedback loop that tightens pre-payment rules over time

Investigation & Case Management

Findings become tracked cases with documentation, so nothing stalls between analytics and action.

Case files with linked claims, documents and correspondence
Status tracking from referral to resolution
Documentation packaged for internal SIU or external referral
Reporting on savings identified, recovered and prevented

Patterns we look for

Thresholds and rule sets are agreed with your team, so review volume matches the capacity you actually have.

Duplicate and split billing
Upcoding and unbundling patterns
Services billed outside a provider's scope
Member eligibility and identity mismatches
Billing volumes that outpace peer providers
Claims for dates of service that cannot occur

No-cost revenue check

See exactly what your practice is leaving on the table

Our billing assessment team reviews a sample of your claims, denials and aging AR, then walks you through the findings. Most practices are surprised by the first slide.

A claim-level look at what is being denied and why
Aged AR you can still recover, quantified in dollars
Coding and fee schedule gaps costing you per visit
A plain-English action plan you can keep either way

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