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.

Get a custom proposal All payer services

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

Built for health plans, TPAs and MCOs

Get a custom proposal for your plan operations

Tell us your payer type, membership and the work you want to hand off. We come back with a scoped proposal covering turnaround, accuracy standards, staffing and pricing.

Scope and turnaround commitments for your claim and document volumes
Dedicated, trained teams that scale through enrollment peaks
Accuracy, audit and HIPAA-minded controls documented up front
Transparent pricing tied to the volumes you actually process

Prefer to talk first? Call 630-430-1040

Get a custom proposal

Tell us about your plan and volumes. We'll come back with scope, staffing and pricing built for your operation.