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Fraud Solutions

Harness the power of innovation to fight a multibillion dollar problem.

Fraud costs U.S. healthcare payers at least $80 billion a year, according to the Coalition Against Insurance Fraud. HMS® can help you make a difference.

Fraud is an arms race. As detection techniques evolve, criminals and their schemes become increasingly sophisticated. In order to stay ahead, it’s imperative for health plans and government agencies to engage an agile, evolved, and mature detection system: HMS Fraud Solutions.

Our system offers two modes of delivery: the Payment Integrity Portal and SIU Support Services. Our Portal – a Software as a Solution (SaaS) offering – gives you the power of analytics in order to identify and prevent fraud on your own. And with SIU Support Services, our analysts can apply our technology on your behalf to identify fraud targets and perform comprehensive investigations.

Our Payment Integrity Portal features a clean design that promotes understanding through clear data visualization, easy-to-use tiles on a mobile- and tablet-friendly platform. Key features include Guided Analytics, Link Visualization, profiles for all providers, provider risk scoring, Lead Management, Case Management, custom watches and alerts, and dashboards for relevant information.

SIU Support Services does the work on your behalf in two ways:

  • Analytics Support. Our analysts perform in-depth analysis, leveraging existing and experimental tools to identify potential fraud targets – from providers, facilities, and members to trends within your business and potential policy gaps. We provide TRAP (Target, Review, Assess, Pursue) reports detailing the methods and recommendations for each issue.
  • Investigation Support. HMS provides background research on providers, licensing and sanction/exclusion checks, medical record review, patient interviews, and detailed claim line findings – both for health plan Special Investigation Units and state Medicaid Fraud Control Units.

Fraud Solutions also complements several of our other products, including Claim Edits and Analytics, Clinical Claim Review, and Prior Authorization.

Fill out the Contact form to learn more about Fraud Solutions.