Stop fraud, waste and abuse with the best defense available

$828 million: That’s the amount recovered by the Medicaid Fraud Control Unit in convictions, settlements and judgements against providers in 2020.  These providers range from hospitals and physicians to personal care services agencies, durable medical equipment suppliers, nonmedical transportation services and substance abuse treatment centers. The scope of fraud and the amount of oversight required to prevent it far exceeds the resources agencies can provide on their own.

We can help you uncover the complex relationships between individuals, entities and claims data. Our near real-time identity intelligence and visualization tools detect patterns and outliers that may indicate individual or concerted fraud efforts. See not only the immediate individuals and businesses, but also their expanded networks of relationships. Claims analytics can flag suspicious activity such as unusually high levels of claims of a certain type.

Benefit from our comprehensive coverage of providers, including 25% more small business coverage than other data providers. This gives you visibility into smaller entities such as sole practitioners. Our databases include:

• 9 million providers and 1.5 million healthcare organizations
• 40 million business uniquely LexID-identified from a universe of more that 4 billion business records 

We can aggregate consumer and business data into a single view of the business, the people connected to it, and their networks of relatives and associates. 

At no additional cost to your agency, we offer the support of a Special Investigations Unit (SIU) to help you with specific concerns or strategic guidance.

Comprised of former law enforcement, national security intelligence, military intelligence and overall fraud experts, SIU stands ready to provide real-time monitoring and investigative insight on identity theft and fraud, waste and abuse patterns and emerging trends ⏤ gleaned from our experience working with all sectors of government.

Count on SIU’s expertise to:

• Assist with specific cases
• Research identified fraud patterns 
• Review your agency data to uncover concerning trends
• Advise on identity threats in general 

Reduce and recover overpayments without negatively impacting claims processing. Our solutions provide critical tools to help prevent duplicate benefits and recoup overpayments without impeding claims processing. Speed is of the essence, especially since payees have 60 days to report and return an overpayment, which considerably impedes your agency cash flow. 

Back-end intelligence and automated payment decision tools perform daily rules-based screening for faster flagging of potential fraud, waste and abuse. Quickly release acceptable claims, and launch full investigations on suspicious ones. You can also filter and focus “pay and chase” activities on those that owe the most or have the greatest compliance impact.  

Create a more efficient, integrated defense against known violators. Back-end intelligence and automated tools also help you identify suspect data and the severity of a scheme for better execution of fraud prevention analytics. Post-payment analytics can feed back into our pre-payment tool for a closed-loop system. If suspicious activity is detected during post-payment claims, you can immediately pause additional claims for further review prior to payout.