The Next Generation: 3 Proven Strategies to Reduce Healthcare Fraud, Waste and Abuse

by LexisNexis

Healthcare spending is at its highest levels in history and fraudulent schemes are becoming ever more sophisticated. As the scope of the industry expands, so does the number of "bad actors", putting nothing short of the health and welfare of our population at risk. The best solutions will be cost-effective, scalable, and easy to implement into existing workflows.

Thinking Inside the Box With a Provider Decision Quadrant

by Verscend

The provider decision quadrant is a visual decision-making framework that can help a health plan increase both its SIU's operational efficiency and claim payment accuracy without adding staff. This allows a plan's SIU to take meaningful provider action by developing actionable leads, prioritizing potential cases for evaluation, and making decisions earlier in the investigation process.

Behavioral Analytics


In order to truly thrive in a value-based world, it is essential for healthcare organizations to look beyond traditional data sources and develop a greater understanding of the factors that drive their populations' decisions. Creating and maintaining personas, or sub-groups of patients or members that share similar characteristics, should be considered a best practice for attaining these actionable insights.

Finding and eliminating fraud

by LexisNexis

Fraud on health exchanges is becoming an increasingly large problem for health plans. While most brokers operating exchanges fulfill their obligations, new entrants have increased the potential for fraud and abuse.

Game-Changing Medicaid Fraud Prevention

by LexisNexis

Until recently, Medicaid Fraud Control Units (MFCUs) were unable to leverage federal funds to mine Medicaid data for the purposes of detecting and mitigating fraud. However, the rules have changed and that restriction has been lifted.

Health Care Payment Integrity through Advanced Analytics

by SAS Institute

How much are fraud, error, waste and abuse costing your organization? Costs to insurers are huge - as much as 25 percent of payments made. This paper discusses how today's data management and analytics platforms promise breakthroughs by using data to predict and detect loss in all its forms.

Public Records for Health Care

by LexisNexis

The United States now spends about $2.6 trillion annually on health care (17.5 percent of GDP) and with the reform initiatives under the Affordable Care Act (ACA), the number of Americans covered and the amount spent will grow dramatically, potentially leading to even greater fraud, waste and abuse in the system.

Revolutionizing FWA detection with a fully integrated software solution - FWAShield

by Healthcare Fraud Shield

Healthcare Fraud Shield is a provider of dynamic fraud, waste and abuse detection software solutions that have dominated the complex financial services industry over the past fifteen years. Our suite of products introduces several new technology applications to the healthcare industry that will revolutionize cost reduction opportunities. Read more to find out about our products and services.

Turning Fraud, Waste, and Abuse Leads into Turnkey Allegations

by Verscend

The exact amount of money lost each year to healthcare fraud, waste, and abuse (FWA) is difficult to precisely quantify, but estimates typically are in the hundreds of billions of dollars. Although a portion is due to waste, a troubling amount continues to be attributable to fraudulent and abusive practices, ranging from upcoding, overcharging, and medically unnecessary billing to complex collusion.