In 2016, the federal government estimates that states improperly paid 6.7% of $262 billion in Medicaid claims. This represents $17.5 billion in improper payments. Sophisticated fraudsters constantly devise new computer programs and identity theft schemes for this “target rich” environment.
Pondera’s System, built “by investigators, for investigators”, offers an extremely powerful, yet easy-to-use system to combat fraud, waste, and abuse in Medicaid. Our integrated system spans fraud detection, investigation, and enforcement.
Detect Medicaid Fraud Fraud Detection as a Service (FDaaS)
: Core detection system that includes over 290 Alerts, Prediction Models, and Geospatial Analysis Maps designed specifically for state Medicaid programs. Validates all providers, beneficiaries and claims. Searches for issues such as ghost beneficiaries, fictitious providers, unnecessary procedures, drug diversion, claim spikes, frequency anomalies, and more.
Fraud Risk Scorecards: Combine data matching services and behavioral flags to generate a fraud risk score for every provider and beneficiary in your program. Stack rank all program actors to prioritize enforcement activities. Create custom scorecards based on your own investigative experience and apply that to the entire program database.
Investigate Medicaid Fraud
SuperSearch: Search the FDaaS database and integrated public records databases for information on providers, beneficiaries, associates, affiliates, and more. Hyperlink to provider and beneficiary profiles for more information such as fraud indicators, alert and claims history, geospatial maps, and Google Street View of locations.
Network Analyzer: Visually explore associations and network linkages between and among Providers and Beneficiaries. Use pre-built Medicaid templates for issues such as shared beneficiaries and corporate associations. Save and share maps with fellow analysts and investigators.
Social Media Analyzer: Discover connections, associations, and investigative data through analysis of social network sites, blogs, and other on-line services. Save newly discovered links to your link analysis charts or open cases.
Fraud Caster: Capture interview and audit data and access key Pondera data while conducting investigations in the field. Securely obtain data when you need it rather than after you return to your office.
Enforce Medicaid Rules
Case Tracker: Create, manage, collaborate, and report on cases generated by Pondera or through tips or other automated systems. Add notes, documents, and images to your cases.
Intel Reports: Request in-depth investigative reports from Pondera’s Special Investigation Unit (SIU), staffed by certified fraud examiners, Medicaid experts, and former law enforcement agents. Reports include behavioral, link, and social network analysis.
Executive Dashboard: Easily review the results of your detection and enforcement activities via a graphical management reporting system. Analyze your program’s most frequent Alerts, associated dollar amounts, and trends over time.
Pondera’s entire suite of tools is fully integrated, passing data and leads between the detection, investigation, and enforcement modules. Your analysts and investigators access the system through a secure Internet Browser. Additional advantages of Pondera include:
- Rapid Deployments : Go live in as few as 120 days
- Cloud Infrastructure : No need to buy hardware or software
- Machine Learning : Identify emerging fraud trends with constantly improving algorithms
- Integrated Third Party Data : Validate identities, incarceration status, addresses, criminal histories, and more with pre-tested consumer and business databases