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Gain leverage using HCL’s intelligent rule based FWA solution to proactively identify potential fraud cases, wasteful and abusive billing practices and avoiding pay and chase scenarios.

The potential for healthcare fraud, waste, and abuse has been rising along with escalating healthcare costs. The technical challenge of sifting through mountains of data for signs of suspicious behavior has overwhelmed the capacity of health plans and law enforcement agencies alike. The urgent need is for a new paradigm, whereby health plans can identify instances of fraud by performing pro-active analyses of new claims and through retrospective trending.

Health plans can gain leverage by utilizing HCL’s full service and customized fraud, waste and abuse solution. The use of data-driven analytics provides insight to aberrant claims, enabling the payer to detect potential fraud and wasteful or abusive billing patterns (either pre-payment or through a fast-tracked post-payment review).

HCLs Fraud, Waste and Abuse (FWA) Management Services cover the full spectrum of validation of suspected claims through recovery management of overpaid claims. These services are supported by tools that aid in providing actionable information for further investigation and workflow management.

The FWA Services include:

  • Claims Validation Services that consist of reviewing claims for potential fraud, waste or abuse (eg: up-coding, drug diversion, medical necessity etc)
  • Recovery Services on claims that warrant a recovery effort with management reports for tracking all activity throughout the audit process
  • Rule and Model Enhancement Services for continuous research and building of a rigorous modeling approach on claims received to enhance the rules, algorithms and modules

The FWA detection and workflow management tools that support the services are:

  • Rule Engine that comprises of customizable rules to identify suspected claims and present the output as claim flag indicator, reason and description
  • Scoring Engine which includes multi-factor predictive models to score claims and provides a probabilistic score for fraud detection
  • Workflow Management Tool to enable the review and tracking of the suspected claims through automatic queuing and alert generation capabilities across multiple roles (e.g, Claims Analyst, Recovery Analyst, Manager etc.)
  • Reporting Dashboard to generate customizable operational and analytical reports

Key features of HCL’s FWA Management solution are as follows:

  • An automated solution that can be integrated with payer systems
  • Analysis of 100% of claims received
  • Identification of aberrant billing practices through a powerful analytics engine
  • A dashboard that provides analytical reports on trends and patterns of fraud, waste and abuse
  • Prevention of prepayment losses through a powerful rules engine
  • Claim auditing and recovery services
  • End-to-end validation services with recovery management
  • HCL’s claim validation services ensure that only the most suspicious claims are referred to the special investigation unit

HCL’s FWA Solution has been developed using Pega PRPC. Pega BRE is used for developing the core Rules Engine that flags aberrant claims which is based on extensible framework of Rule Categories. The work flows and alerts for Validation Services have been developed using Pega BPM.

HCL’s FWA solution leverages comprehensive Case Management capabilities of Pega BPM providing a complete view of the case. The solution also provides configurable service levels for alerts and investigations to ensure regulatory and internal control management and automated correspondence. Additionally, Pega BPM’s reporting capabilities are leveraged to provide various KPI reports and intelligence inputs needed for performing rule refinements.


HCL FWA Solution Architecture using Pega Solutions / Frameworks

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