Fraud Solutions

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

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According to the Coalition Against Insurance Fraud, fraud costs U.S. healthcare payers $80 billion a year.

As fraud 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 and innovative detection system: HMS Fraud Solutions.

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

Our FraudCapture platform 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 AnalyticsLink Visualization, profiles for all providers, provider risk scoring, Lead ManagementCase Management, custom watches and alerts, and dashboards for relevant information.

FraudCapture SIU 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.

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

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