Clinical audit and fraud and abuse services for healthcare payers

CGI offers a comprehensive line of services and software solutions to ensure claims integrity and accuracy. This wide range of offerings is designed to enable payers to achieve appropriate reimbursement and protect provider relations.

Some of these service offerings include:

Provider audit software and services

Our expertise has shown that 1% to 3% of provider claims can contain errors due to data entry mistakes, carelessness, gaming, lack of coding knowledge or upcoding.

Our diverse and experienced staff has created the most effective and efficient solutions available. Our highly successful and flexible tool-sets allow us to adapt what we do to how you conduct your business. In order to maximize your return on investment in selecting CGI as your business partner, we don’t believe in “shrink-wrapped” or “off-the-shelf” solutions. Our methodologies review every claim you processed and are at risk for, including inpatient, outpatient, physician, ancillary, pharmacy, DME and home health. This will ensure that you are presented with the most comprehensive and effective compliance program available.

To further ensure that we provide you with the highest level of service, our solutions are available through a variety of delivery mechanisms, including, full outsourcing, a co-sourced arrangement or through software licensing arrangements.

Clinical systems development:

CGI’s suite of clinical systems for payers include utilization management systems, case management systems, payment processing systems and provider network management systems. We also focus on developing, enhancing and maintaining claims, billing, and capitation systems for payers across the United States.

Fraud and abuse software and services:

Ensuring that you have an effective fraud program is essential, but being sure you have the correct focus and a well-defined end result is equally important. CGI has been at the leading edge of the development of effective and comprehensive healthcare fraud programs for more than a decade. Our focus, tools and methodologies are all designed to ensure that the integrity of your health plan is protected at all times. This level of effort and commitment only further demonstrates to your members, your physicians, and your self-funded accounts that you are serious about protecting them.

Pharmacy claims auditing and analysis:

To combat the dramatic increase in pharmacy costs, CGI has developed software solutions and consulting services that can be integrated or used alone to help payers review pharmacy claims and identify those with the highest probability for error. Our methods entail the review of both the PBM and the retail pharmacy, ensuring the broadest possible review and best possible outcome. Through a multi-pronged approach, CGI will audit pharmacy claims processed internally by your plan, or by your PBM through extensive electronic claims investigation, subscriber surveys, field audits and our unique cost avoidance solution called Push Technology.

Pharmacy benefit consulting:

The trend in increased pharmacy costs has increased the importance for payers and PBMs alike to create programs and strategies for effective pharmacy program management and cost containment. The suite of CGI pharmacy services identifies methods to contain costs, develop future corrective action strategies and optimize performance. All our solutions are customized to meet your plan’s specific needs and initiatives.