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Program Integrity Solutions

Program Integrity Solutions

It is estimated 3-10% of healthcare expenditures are fraudulent* – $90-100 billion – and less than one percent is recovered each year+. In addition, identify theft and increasing coordination with organized criminal entities, poses an even greater threat to healthcare beneficiaries. Challenged with disparate record systems and data, overwhelmed or insufficient staff, and regulatory and financial requirements, health payers require program integrity solutions to detect and deter fraud and overpayments, aid in recoveries, and meet compliance and financial goals.

Maintaining an effective program integrity program can be cumbersome and costly – requiring intensive recruitment, training and retention of staff with high-value skills. Some organizations look to outsource entire programs while others look for solutions they can integrate with their in-house capabilities. With a wide range of anti-fraud services and products, General Dynamics Health Solutions provides health payers with custom solutions to better manage anti-fraud programs and investigative costs, comply with regulatory requirements and augment staff expertise.

Services include: Lead generation and assessment, investigative support, clinical review services, claims verification services, training, consultative support and more.  

STARSSolutions®

Designed with clinicians, claims and regulatory experts, administrators and data analysts, our STARSSolutions® software drives insight and analysis from complex data and monitoring modules to help track fraud, waste and abuse. Whether supporting our customers on-site or through a HITRUST managed cloud hosting environment, our tools include:

  • Pre-payment Analysis: STARSInterceptor® helps organizations anticipate and prevent fraud, waste and abuse by identifying aberrant utilization patterns, coding mismatch and billing-payment activities
  • Post-Payment Detection: STARSSentinel ® supports post-pay detection by examining utilization measures, financial profiles and high-impact fraud schemes to identify suspicious activity
  • Case and Workflow Management: STARSCommander® helps payers build, track and learn from caseloads to better capture, control and report program integrity data
  • Investigative Analysis: STARSInformant® supports advanced data mining and analytics to better assemble vast data and reporting outputs for strong exploration.

 *National Healthcare Anti-Fraud Association        +National Health Expenditure Fact Sheet

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Schedule a demo to learn how we can help your FWA, HEDIS and/or quality improvement efforts.
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