Fraud Solutions Index

NHCAA's Platinum, Premier and Supporting Members are leading providers of products & services to the health care anti-fraud industry, are valued partners who support our mission, and have demonstrated outstanding commitment to the fight against health care fraud.

PLATINUM SUPPORTING MEMBERS

Change Healthcare
3055 Lebanon Pike
Nashville, TN 37214

Phone: 615.932.3000
Website: http://www.changehealthcare.com/


Change Healthcare

Change Healthcare is a leading provider of software and analytics, network solutions and technology-enabled services all designed to enable smarter healthcare. By leveraging our Intelligent Healthcare Network the single largest financial and administrative network in the United States healthcare system – payers, providers and pharmacies are able to improve efficiency, reduce costs, increase cash flow and more effectively manage complex workflows. Learn more at www.changehealthcare.com/solutions/payers.

Cotiviti
One Glenlake Parkway
Suite 1400
Atlanta, GA 30328

Phone: 866.292.6971
Email: answers@cotiviti.com
Website: cotiviti.com/solutions


Cotiviti

Payment integrity leadership requires experience, scalability, innovation, and proven value. Cotiviti has spent 20+ years honing our solutions specifically to drive exceptional value for our clients all along the claim payment life cycle -- from prospective payment policy management and clinical coding review to both pre-and post-pay chart review and fraud investigation. We help clients work more effectively across their payment accuracy iloes by deploying the right approach at the right time, driven by a full-service model and the deepest industry expertise.

Deloitte
1919 N. Lynn Street
Arlington, VA 22209

Phone: (203) 905-2854
Deloitte.com/us/program-integrity
Email: danolson@deloitte.com

Deloitte

Strategic. Measurable. Actionable. Government agencies that provide public benefits are looking for ways to drive greater impact in the services they provide. Ensuring that payments are managed properly and getting the right payment in a timely manner to the right individuals is critical for agencies to achieve their objectives. Deloitte can work with you to design and help improve program integrity strategies to support greater program impact. Our experience and holistic, enterprise-wide approach—technology through people —helps agencies move beyond pay and chase using predictive analytics to identify anomalous provider behavior and avoid improper payments.

Deloitte has an unparalleled history of defining innovative strategies and implementing leading practices across government entities and addressing the demands of myriad stakeholders throughout all branches of federal, state, and local government. Our industry experience provides us with unique end-to-end payment lifecycle insights from program funding, to processing and management, and payment.

FraudScope
75 5th St NW, Ste 2170
Atlanta, GA 30308

Phone: 770-547-8798
Website: https://www.fraudscope.com/
Email: info@fraud-scope.com

FraudScope

FraudScope is an AI-assisted platform that accelerates the identification of fraud, waste, and abuse. Our comprehensive claims investigation platform utilizes proven and patented AI-based technology to empower investigators and analysts to derive insights and conduct full investigations of suspect claims. Some of the unique benefits of FraudScope's offering are as follows:

  1. Smarter Investigation - Intuitive, easy-to-use investigative tool suite enhances productivity by speeding up investigations
  2. Better Detection - Proactive AI automatically identifies fraud schemes, including new and emerging ones, with low false positives
  3. Easier Collaboration - Integrated workflow and case management supports collaboration and sharing across the organization

Healthcare Fraud Shield
16052 Swingley Ridge Road
Suite 200
Chesterfield, MO 63017

Phone: 888.333.8140
Website: www.hcfraudshield.com
Email: info@hcfraudshield.com

HFS

Healthcare Fraud Shield was founded in 2011 to offer innovative fraud, waste, and abuse (FWA) solutions to the healthcare insurance industry. The focus of Healthcare Fraud Shield is solely on healthcare fraud prevention and payment integrity with a successful approach based on many unique advantages we deliver to our clients.

Healthcare Fraud Shield’s fraud, waste, and abuse software as a service platform – FWAShield – is an integrated solution consisting of PreShield (pre-payment), AIShield (AI), PostShield (post-payment), RxShield (pharmacy analytics), QueryShield (ad hoc query and reporting tool) and CaseShield (case management).

FWAShield was developed by industry leading healthcare subject matter experts with the latest technology available today to provide the most affordable, flexible, transparent, efficient, and effective solution in the marketplace.

HMS
5615 High Point Drive
Irving, TX 75038

Phone: 214.453.3000
Website: hms.com/
Email: info@hms.com

HMS

HMS advances the healthcare system by helping healthcare organizations reduce costs and improve health outcomes. Through our industry-leading technology, analytics and engagement solutions, we save billions of healthcare dollars annually while helping consumers lead healthier lives. HMS provides a broad range of coordination of benefits, payment integrity and population health management solutions that help move the healthcare system forward. Visit us at www.hms.com and follow us on Twitter at @HMSHealthcare.

MultiPlan
115 Fifth Avenue
New York, NY 10003

Phone: 781-895-3118
Website: https://www.multiplan.us/

Multiplan

MultiPlan offers a total healthcare cost containment solution that includes payment integrity, network-based and analytics-based services, helping payers reduce the cost of care and improve competitiveness. Unlike similar products, MultiPlan's payment integrity services include a personal review by an experienced clinician in addition to automated reviews. This human touch allows us to catch more complex issues indicative of waste and abuse, that go undetected by other products. For 40 years, we've processed claims prepayment. Today more than 1 million providers participate in our networks, partnering with us to control claim costs. This rich history helps us resolve medical and dental payment integrity issues quickly while minimizing provider abrasion – all before our clients pay a dime.

Optum
11000 Optum Circle
Eden Prairie, MN 55344

Phone: 800.765.6807
Website: www.optum.com
Email: empower@optum.com

OPTUM

At Optum, we are a leading health services innovation company dedicated to helping make the health system work better for everyone. We create simple, effective and comprehensive solutions for organizations and consumers across the whole health system by integrating our foundational competencies of consumer experience, clinical expertise, data and analytics, and embedded technology into all Optum services. By understanding the needs of our customers, members and patients and putting them at the center of everything we do, we will achieve our aspiration of improving experiences and outcomes for everyone we serve while reducing the total cost of care.

SAS
100 Campus Dr
Cary, NC 27513

Phone: 919.677.8000
Website: www.sas.com/security

SAS

SAS is the leader in advanced analytics software and services, and the largest independent vendor in the business intelligence market. With SAS® payment integrity solutions, health care organizations can detect suspicious activity, prevent improper payments, and uncover collusion and multiparty fraud schemes. Since 1976, SAS has given customers around the world THE POWER TO KNOW®.

Shift Technology
75 Federal Street, 18th Floor
Boston, MA 02110

Phone: 1.860.227.5173
Website: www.shift-technology.com
Email: robert.mcginley@shift-technology.com

Shift

Shift Technology delivers an AI-native fraud, waste and abuse detection solution designed to meet the evolving needs of the global health insurance industry. Our SaaS solutions identify suspicious claims activities related to providers, networks and other parties with double the accuracy of competing offerings. To date, Shift has analysed more than one billion claims for leading insurers around the globe enabling faster, more accurate claims resolutions while helping to eliminate fraud, waste and abuse. Learn more at shift-technology.com.

Truven Health Analytics, an IBM Watson Health Company
777 Eisenhower Parkway
Ann Arbor, MI 48108

Phone: 734.913.3432
Website: www.ibm.com/watson/health/government
Email: David.Nelson@us.ibm.com

Truven

IBM Watson Health™ helps state Medicaid programs and federal agencies manage healthcare quality and ensure program integrity. With broad fraud-fighting experience, our unique combination of data-driven enterprise transformation and advanced analytics can help you fight healthcare fraud, waste and abuse at every stage. Our suite of program integrity analytics, tools, and services includes identity verification & enrollment, pre- & post-payment analytics, investigative support, and audit & recovery. For more information, visit: https://www.ibm.com/watson/health/government/.

 

PREMIER SUPPORTING MEMBERS

EXL Healthcare
320 Park Avenue
29th Floor
New York, NY 10022

Phone: 1.800.653.3144
Website: www.exlservice.com/healthcare
Email: lookdeeper@exlservice.com

EXL

EXL combines unmatched healthcare domain expertise with data-driven insights and digital technology to transform how care is delivered, managed and paid. This ensures our clients achieve high-quality, effective healthcare at an appropriate cost.

Our digitally-enabled transformation solutions orchestrate innovation, automation and performance excellence to impact payment accuracies, cost management, quality outcomes, and appropriate utilization ― all key to value-based performance.

Covering more than 150 million lives, EXL partners with healthcare organizations across payers, providers, PBMs, and life sciences organizations to deliver deeper value. We do this through what we call Digital Intelligence, the orchestration of domain and data, people and technology, to deliver breakthrough business outcomes.

 

SUPPORTING MEMBERS

AmerisourceBergen
500 North State College Blvd
Suite 900
Orange, CA 92868

Phone: 610.727.7000
Email: solutions@amerisourcebergen.com
Website: www.amerisourcebergen.com/

AmerisourceBergen


AmerisourceBergen is a leading global healthcare solutions company. The company drives innovative partnerships with pharmacies, health systems, practices and manufacturers to improve product access, increase supply chain efficiency and enhance patient care. Customers count on AmerisourceBergen for comprehensive services and solutions across the healthcare supply chain - from commercialization and distribution to pharmacy, health system, practice and manufacturer solutions. The company's extensive knowledge, global reach and innovative partnership philosophy enable them to help customers capitalize on the dynamic changes in healthcare. With more than $120 billion in annualized revenue, AmerisourceBergen is the leader in global sourcing and distribution and employs approximately 16,000 employees worldwide from their headquarters in Conshohocken, PA. AmerisourceBergen. Where knowledge, reach and partnership shape healthcare delivery. For more information, visit www.amerisourcebergen.com.

Affiliated Monitors, Inc.
P.O. Box 961791
Boston MA 02196

Phone: 866-201-0903
Email: info@affiliatedmonitors.com
Website: www.affiliatedmonitors.com

AMI

Affiliated Monitors, Inc. (AMI) - provides independent integrity monitoring and IRO services in healthcare and other industries. Since 2004, health regulatory authorities in most states, including state Attorneys General Medicaid Fraud Offices, State Departments of Health, and the HHS Office of Inspector General, have trusted AMI to successfully monitor more than 800 matters involving hospitals, healthcare providers, surgical centers, skilled nursing facilities, home health agencies, diagnostic laboratories and many others. AMI’s monitoring services are being used with greater frequency by insurance networks to oversee the implementation of corrective action plans by providers. One significant benefit of AMI’s services is that the monitoring costs are paid for by the individual or entity being monitored. AMI also provides proactive assessments of corporate compliance programs and compliance and ethics culture. Our approach is practical and remedial: we recommend improvements, share best practices, and help remediate areas of concern. AMI’s monitoring provides healthcare organizations with guidance needed to achieve and demonstrate sustainable compliance. www.affiliatedmonitors.com

CGI Federal Inc.
1001 Lakeside Avenue
Suite 800
Cleveland, Ohio 44114-1151

Phone: 410.279.0996
Website: www.cgi.com/healthcare
Email:healthcompliance_BD@cgifederal.com

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CGI, a global IT and consulting company, is an industry leader in identifying improper payments and assisting healthcare payers to control costs. Our fraud, waste and abuse solution, ProperPay, includes data mining functionality, algorithms and edits to identify improper payments and other features that increase efficiencies in the audit and recovery process.

Coalition Against Insurance Fraud
1012 14th Street, NW Suite 1105
Washington, DC 20005

Phone: 202-393-7330
Email: info@InsuranceFraud.org
Website: www.InsuranceFraud.org

Coalition

Founded in 1993, the Coalition Against Insurance Fraud is a nonprofit alliance of consumer groups, insurance companies, government agencies and other partners combating all forms of insurance fraud through advocacy, public education and research. The Coalition has more than 210 member organizations.

Context 4 Healthcare, Inc.
55 Shuman Blvd., Ste 650
Naperville, IL 60563

Phone: 800-783-3378
Website: www.context4healthcare.com

Context4

Context 4 Healthcare is the leading provider of cloud-based healthcare compliance solutions in verifying medical claim accuracy for health plans and benefits administrators. These solutions are designed to review for complex coding accuracy, identification of potential fraud, waste, and abuse (FWA) situations before the claim is paid, and to review for potential FWA situations in claim history. Context's Medical Director and our team of certified claim experts maintain solution rules weekly for up-to-date compliance and identification of potential new FWA schemes. The semi-annual creation of our proprietary UCR fee schedules is also a source for identifying potential FWA situations leading to new solution rules, a capability unique to Context. Our experts also blog for your benefit, letting you know about emerging situations that may affect your compliance, and what Context is doing about it. Since 1988, Context has been the healthcare industry's leading compliance specialist.

Mastercard
2000 Purchase Street
Purchase, NY 10577-2509

Phone: 914.249.2509
Website: www.mastercard.com

Mastercard

Mastercard Healthcare Solutions provides a proven AI solution that differentiates by leveraging its experience in payment fraud to complement claim fraud mitigation. Mastercard Healthcare Solutions’ unique competency supports post-pay detection, while also creating prospective (pre-pay) models built by identifying anomalies found in historical claims data (post-pay). In this webinar, you will learn how you can increase detection of fraud, waste and abuse (FWA) before sending good money for bad claims, significantly reducing inefficient pay-and-chase activities while moving toward a prevent and save business model. With increased detection of true FWA, false positives are greatly reduced, anomaly detection is significantly increased, and payers can focus their investigators’ time on highly-likely FWA.

MITRE
202 Burlington Rd
Bedford, MA 01730-1407

Phone: 781.271.2000
Website: http://mitre.org/

MITRE

MITRE is a not-for-profit organization that operates research and development centers sponsored by the federal government.

We operate FFRDCs-federally funded research and development centers-which are unique organizations that assist the United States government with:

  • Scientific research and analysis
  • Development and acquisition
  • Systems engineering and integration

We also have an independent research program that explores new and expanded uses of technologies to solve our sponsors' problems.

MITRE's Sole Focus Is to Operate FFRDCs

MITRE is chartered to work in the public interest. We have no commercial interests. We have no owners or shareholders, and we can't compete for anything except the right to operate FFRDCs. This lack of commercial conflicts of interest forms the basis for our objectivity. We also have the ability to acquire sensitive and proprietary information from the government and industry to inform our work. These organizations are able and willing to share data because they know we won't use it for a competitive advantage.

Moreover, because we operate multiple FFRDCs, we foster a culture of knowledge sharing. We apply what we learn from addressing one sponsor's challenges to similar issues faced by other federal agencies. This means when sponsors engage with us, they have access to all the minds of MITRE.

Verisys® Corporation
1001 N. Fairfax Ave
Suite 640
Alexandria, VA 22314

Phone: 888.837.4797
Website: www.verisys.com
Email: info@verisys.com

Verisys NEW

Verisys® provides health care compliance professionals with the tools they need to prevent waste, abuse, and fraud committed by high-risk people, professionals, and businesses. We are the leading provider of sanctions, exclusions, and disciplinary actions. Our flagship product, FACIS®, offers a full complement of primary sources to monitor licensure, DEA, criminal, sex offender, abuse registries, and more.