Fraud, Waste, and Abuse Identification and Prevention

Every year HMS reviews more than 8 billion claims for fraud, waste, and abuse—all part of our comprehensive suite of program integrity solutions, HMS IntegritySource℠.

Our Fraud, Waste, and Abuse Identification and Prevention solution identifies aberrant providers, tracks member behavior, and uses powerful analytics to interrogate claims—from prepay through recoveries. We back that system with a team of certified coders, fraud examiners, and medical professionals.

Our system uncovers such violations as duplicate claims, abuses of program policy regulations, inaccurate application of billing codes and modifiers so we can easily find targets through coding, compliance, billing, network, geospatial, and behavioral analysis.

Our solution includes three components:

  1. handcuffsPrepay Clinical Reviews. Payers can check inpatient claims against medical records before paying. HMS gets results through our years of experience in the field. By performing clinical reviews on a pre-pay basis, you can resolve problems and errors early in the payment continuum, avoiding the costs of pay and chase.
  2. Forensic Coding and Predictive Analytics. We use the broadest range of edits and algorithms to review claims for error and potential abuse before you make payments. Our forensic coding and data analytics are customized to federal and state regulations, and to your own policies. Our platform learns from historical claim data to find fraud, waste, and abuse.
  3. Investigations Support. HMS offers full analytical, clinical, and investigative support to help payers address issues related to fraud, waste, and abuse. HMS’s analysts can help you do everything from identify high-risk targets to pursuing recoveries.

Choose any or all of these services—the better to meet the needs of your agency or plan.