A number of Blue Cross Blue Shield health plans required a claims audit tool to identify and recover improperly paid claims.

They needed a system to detect and prevent potentially fraudulent payments and required a case management system to manage the end-to-end audit workflow. Support was also needed to maintain reimbursement systems, including prospective payment systems (PPS).

CGI provided effective services and solutions to address these challenges.

Value delivered

  • Identified more than $1 billion in recoveries of improperly paid claims
  • Developed a model that identifies new audit concepts, leveraging machine learning
  • Created a centralized repository of audited case results
  • Implemented a provider web portal to enable transparency
  • Enabled alignment with payer policies and methodologies, using CGI ProperPay’s configurable edits


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.