Healthcare claims fraud, waste and abuse

Predicting, preventing and recovering improper payments

CGI has been a leader in healthcare claims auditing and recovery since 1990. Our solution and services for reducing claims fraud, waste and abuse (FWA) have helped Medicare, Medicaid and commercial payers recover more than $2.1 billion in lost payments due to improper claims in the past 5 years alone. We also offer anti-fraud solutions to help detect, remedy and prevent claims fraud, pre- and post-payment.

CGI’s proven FWA solution is configurable to an organization’s specific business rules and reimbursement methodologies. Its technology, predictive analytics and global best practices soon will be available in the secure Microsoft Azure cloud for even greater elasticity and power, providing:

  • Advanced algorithms to predict hidden patterns and anomalies within the entire claims data universe to identify high-potential claims for recovery, allowing staff to easily work on these claims through a series of edits.
  • Analytics to prevent fraudulent activity and keep patients safe, allowing staff to easily identify patterns and research claims as well as audit data through a series of views. This is accomplished at the user level, freeing up valuable IT resources.
  • Technology to identify, stop and recover improper payments to preserve healthcare funds and revenue.

The solution includes comprehensive identification, auditing workflow and tracking functionality across all provider types and settings, from inpatient to outpatient, professional and pharmacy claims. Efficient workflow tracks the entire audit process, records the findings and generates the associated letters and reports so staff can spend more time on the review process and less time on administrative tasks. Our solution also can support Medicare Risk auditing needs by helping to identify members with missing or under-coded diagnoses and providing the necessary audit processes to enhance capitation revenue.

Our expertise and experience includes:

  • Serving as one of the four permanent Medicare Recovery audit contractor (RAC) firms, covering 7 states and 8.5 million beneficiaries in Region B
  • Performing reviews and audits on behalf of Medicaid, Medicare and commercial payers
  • Breadth and depth of knowledge of a variety of payment methodologies, state and federal regulations and medical policies and contracts unique to each payer
  • Proven claims audit and recovery services that have been used to audit approximately 30 million covered lives by payers ranging in size from 60,000 to 9 million members

For more information, view or FWA solution brochure or contact a CGI representative.