Cognosante Fraud Waste and Abuse

Cognosante provides unparalleled solutions and capabilities to combat fraud, waste, and abuse in our country’s healthcare system

  • Clinical Auto-Coding (CAC)
  • Clinical Intelligence Dashboards
  • Population Health Management
  • Re-admission Prediction
  • Behavioral Health Quality Measures
  • ACO quality measures
  • Unstructured and Structured Data analysis
  • A statistical approach to fraud scoring

Meeting Your Challenges

In the face of growing enrollments and shrinking budgets, our solutions help you reduce and control costs and comply with program integrity provisions in the ACA. We provide proven program management methodologies, best-in-class technology, extensive industry contacts, and innovative best practice approaches. Our solutions are designed to help you implement and optimize fraud, waste, and abuse programs to strengthen enrollment standards, improve prepayment review of claims, and perform post-pay program audits.

Our Solutions and Services

  • Audit Recovery Management System - ARMS™: Helps you identify and manage claims for a full range of audit needs. It delivers automatic claim reviews for fraud and abuse; effective management of investigation case loads; full tracking of activities against audit cases and secure provider access to stay informed of the status of cases.
  • Enhanced Provider Screening: Uses Cognosante’s powerful fraud detection platform and skilled expertise.
  • Medi-Medi: Analyzes Medicaid overpayments based on access to Medicare datasets.
  • Enhanced MMIS: Leverages Medicaid IT expertise to improve collection, normalization and exchange of state health data, developing partnerships to pursue MMIS re-architecture.
  • Electronic Visit Verification: Combines case tracking technologies with scheduling and patient administration systems.
  • Electronic Chart Validation: Builds next generation program audit capabilities, combining health data and IT standards expertise with the application of innovative technology to ensure providers and suppliers are complying with program and national standards.

The Cognosante Difference

  • Improved Compliance: We ensure your compliance with ACA and other health reform and regulatory requirements to strengthen your Medicare and Medicaid enrollment standards.
  • Faster Investigations Saving Time And Costs: We help you automate your investigative process to save you time and money.
  • Enhanced Data Quality: We facilitate collaborative audits through improved data quality and improved integrity in your investigation.

The fight against fraud, waste, and abuse

  • Enable a shift from “pay and chase” to cost avoidance through predictive modeling and pre-pay monitoring
  • Increase audit velocity and accuracy by combining automation and subject matter expertise
  • Use regulatory expertise to support expanded requirements for Healthcare Compliance

Anomaly Detection

  • Automated, semi-automated, and complex provider reviews
  • Analyze multiple data sources with cross-dimensional analytics
  • Detect Improper payments
  • Analyze potential fraud patterns and suspect relationships
  • Conduct Improper eligibility determination