Healthcare Fraud, Waste, and Abuse Detection Software

 

 

Detecting fraud in your agency is an important part of providing quality healthcare. See how Enformion can help with this most essential of tasks.

Healthcare Fraud, Waste, and Abuse Detection Solutions

Healthcare provider fraud
Prevent improper payments
Fraudulent claims for benefits
Transmitting sensitive information safely

Healthcare provider fraud

To combat these concerns, we have created the Enformion for Civil Enforcement software suite. With this, government healthcare officials can research data points relevant to typical provider schemes:

  • Professional licensing data verifies the providers’ licensing.
  • Asset and debt records validate the provider’s claims of financial solvency.
  • US corporate and business records investigate named subcontractors.
  • Personal and business relationships can discover conflicts of interest among related parties.
  • Enformion’s robust person data and identity verification capabilities guard against cases of identity theft and nonexistent patients.

Preventing Improper Payments

From 2003 to 2012, Federal agencies reported more than $1.2 trillion of improper payments. After the passage of IPIA in 2002, IPERA in 20010, and IPERIA in 2012, progress was made on reducing this cost, but improper payments surged in the wake of the Great Recession.

With unprecedented new government spending and economic challenges on the horizon, history may repeat itself, and improper payments will again be on the rise.

Fraudulent claims for benefits

Dual Participation: Whether a beneficiary applies for duplication benefits accidentally or fraudulently, the resulting dual participation creates an undue burden to taxpayers. Our research application and automated batch processing capability provide a turnkey solution for health agency leadership to quickly mitigate this growing problem.

Organized Claims Fraud

Enformion can locate friends, family, and associates for each subject profile that can lead to the discovery of connections between a beneficiary and provider, or among several healthcare providers.

Deceased and Nonexistent Beneficiaries

Most states make minimal effort to discover and remove deceased and nonexistent beneficiaries from social program rosters. For services such as capitated healthcare programs, or providing health HMO insurance coverage, the wasteful cost to taxpayers can be enormous.

Our identity verification and management tools, combined with deceased audit services, assist government agencies with reducing both of these risks.

Transmitting sensitive information safely

Integrating personally identifiable information (PII) into your customer relationship management (CRM) or case management (CM) system can be a complex topic. Enformion provides access to our Application Program Interface (API) to integrate our data into your modern web-based applications.

For legacy solutions, we also offer our Batch File Exchange Services using our fully automated Secure File Transfer Protocol (SFTP) gateway. From your input file, we append and output the content to meet your business requirements. Security policies, procedures, protocols, and Certifications ensure that sensitive information never gets into the wrong hands.

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Frequently Asked Questions

What is healthcare provider fraud?

Government agencies may encounter healthcare provider fraud, which is when a provider submits dishonest forms — sometimes on purpose, sometimes on accident — in exchange for a more substantial amount of healthcare benefits. Healthcare provider fraud solutions from Enformion help agencies act proactively to catch and avoid this fraud before it happens.

How can I access Enformion’s healthcare provider fraud solutions?

All of our data is available via the Cloud-based Platform, Batch, or API with customizable options from one of our data experts.

What data is provided by Enformion’s healthcare provider fraud solutions?

Healthcare provider fraud allows agencies to analyze past instances of fraud and monitor current patterns for fraud. It also verifies that basic healthcare provider information (such as licenses) is accurate, as well as reveals information about people and their relationships that can help you discover potential conflicts of interest.

What is dual participation?

Whether a beneficiary applies for duplication benefits accidentally or fraudulently, the resulting dual participation creates an undue burden to taxpayers. Our research application and automated batch processing capability provide a turnkey solution for health agency leadership to quickly mitigate this growing problem.

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