We live in a world where healthcare needs are seemingly infinite, but resources are finite – so it truly is outrageous that an estimated $455 billion in global healthcare spending is lost every year due to fraud, waste, and abuse (FWA). In the United States, FWA (and the extra rules and inspections required to fight it) cost Medicare and Medicaid $98 billion in 2012, raising their total spending by 10%. The World Health Organization lists FWA among the leading causes of inefficiency in worldwide health. Improper healthcare payments bring up healthcare costs and decrease quality of care by siphoning away funds intended for treatment.
FWA takes many forms – healthcare payers are facing outright fraud, upcoding, unnecessary treatments, doctor shopping, and simple coding errors. Detecting each type of improper payment requires a different approach, and most health insurance plans don’t have the resources to do it on their own.
In an industry where every penny counts, trimming costs without sacrificing quality of care is very difficult. The reality of FWA is unfortunate – but many are finding solutions that offer hope for reducing healthcare costs. Fighting FWA offers the unrivaled potential of reducing spending by billions of dollars, thus making more funds available to improve quality of care. The good news is, the tools to fight improper payments are only getting better.
Fighting fraud, waste, and abuse with analytics
To combat FWA and protect patients, healthcare payers need a powerful data-driven tool to identify potential cases of improper payments that can also manage the data securely. CGI ProperPay, an industry-leading claims analytics solution powered by Microsoft cloud and intelligence technologies, has already recovered billions of dollars for healthcare payers through detection of fraudulent and other improper payments. In the last 5 years alone, CGI ProperPay clients have recovered $2.5 billion of improperly paid medical and pharmacy claims.
CGI ProperPay employs Cortana Intelligence Suite’s advanced techniques including outlier analysis, predictive modeling, and machine learning to detect improper payment scenarios and select cases for auditing with the highest potential for recovery and eliminating false positives. Fully configurable rules can be customized to payer-specific reimbursement policies. Crucially, all data is managed in the highly secure and compliant Azure Cloud, which has been proven as one of the best-equipped cloud environments to protect highly sensitive data.
Healthcare payers using CGI ProperPay have the power to:
- Predict hidden patterns and anomalies with advanced algorithms on Cortana Intelligence Suite
- Prevent fraudulent activity by allowing staff to easily identify patterns and research claims
- Protect health information by storing all data on the highly secure and compliant Azure Cloud
- Preserve healthcare funds and revenue, ultimately resulting in better patient care at reduced cost
CGI ProperPay has a robust history of fighting healthcare FWA – and its new release on Microsoft AppSource makes the solution stronger than ever. The solution has been fine-tuned specifically for the cloud. This means vast improvements in speed, efficiency, and power that further cement CGI ProperPay as a world leader in preventing improper payments.
Healthcare FWA is a reality that affects everyone – but it’s one that we no longer have to live with. In order to protect patients and reduce global health spending, it’s time to bring out the most powerful tools we have to fight improper payments. Healthcare payers interested in preventing, detecting, and recovering improperly paid claims can learn more about CGI ProperPay for claims analytics and try the preview now on Microsoft Appsource Marketplace.