One of the largest U.S. commercial health payers / insurers required a claims audit tool to identify and recover improperly paid claims.

The client needed a system to detect and prevent potentially fraudulent payments and required a data management system to identify suspect members with under-coded or undocumented conditions. They also required a case management system to manage the end-to-end audit workflow.

CGI partnered with the client to provide effective recovery audit services.

Value delivered

  • Identified more than $90 million in recoveries for recoupment in 2020
  • Leveraged machine learning capabilities and developed a model to improve by 100% to realize savings more quickly
  • Furnished a centralized repository of audited case results and a state-of-the-art system streamlining the auditing process
  • Implemented a provider web portal to enable transparency


Learn more about CGI's Payment Integrity Services

CGI’s innovative suite of payment accuracy solutions delivers the best complex-audit-review overturn rates in the market, along with proactive feedback to prevent future errors, enabling payers / insurers to continuously ensure claims payment accuracy while maintaining the highest level of compliance.