What is on the horizon for healthcare payer technology in 2025? In this annual report, ClarisHealth experts review the trending drivers – and associated opportunities – so health plans can innovate payment integrity while minimizing risk.
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Fraud, Waste and Abuse
Maximizing Opportunity with 2025 Healthcare Payer Technology Trends
Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?
Artificial Intelligence is making the leap from much-hyped “trend” for healthcare technology to more widespread adoption. Here’s what A.I. is — and isn’t — and how health plans are proving its value. Artificial Intelligence for healthcare has come a long way since...
Health Plan Leaders Speak Out on Building the Payment Integrity Organization of Tomorrow
Whether or not health plan leaders implement a fully centralized PIO, sharing information on an enterprise payment integrity technology platform helps overcome challenges and meet strategic opportunity.
Modernizing the SIU to Combat Healthcare FWA
For more than a decade, the SIU has relied on reactive business models. But with the rapid gains that artificial intelligence has made, health plans are beginning to embrace more adaptive technology, working smarter to deliver tangible results.
Reduce False Positives in Healthcare Fraud Detection
Part 2 of our series on how the SIU can use artificial intelligence to overcome common challenges. A.I. can reduce the fraud false positive rate to make the most of your limited investigator resources.
Using A.I. to Unite Fraud and Payment Integrity
Part 1 of our series on how the SIU can use artificial intelligence to overcome common challenges. Bringing together fraud and payment integrity efforts on a single A.I.-powered platform can accelerate health plan savings. Data and work silos have become a top barrier...
5 Steps to Reducing Fraud, Waste and Abuse
Use these tech-enabled tips to comprehensively reduce FWA. States require MCOs to take proactive measures that reduce not just fraud, but also waste and abuse. But how can you ensure your efforts not only meet compliance requirements but also help secure a competitive...
What’s your best path to adopting advanced FWA technology?
Take this interactive self-assessment to evaluate your current SIU successes and determine your health plan’s need for advanced technology to level up your fraud, waste and abuse mitigation efforts. More advanced technology solutions for healthcare fraud detection,...
You Don’t Need Rules to Mitigate Healthcare FWA
Health plan SIUs find deep learning models for fraud detection provide advantages over rules-based tools. The onset of the novel coronavirus pandemic highlighted a glaring weakness in rules-based FWA systems: the need to develop rules well ahead of their actual use...
3 Ways MCOs Can Prevent Fraud, Waste and Abuse
A robust fraud, waste and abuse program at MCOs and MAOs includes three key areas: Technology, Clinical Audit and Investigative capability. As your health plan grows its fraud, waste and abuse initiatives, there are three areas a strong prevention plan should address....
Do You Have a Healthcare Fraud Prevention Strategy Ready for COVID-19?
Artificial Intelligence allows health plans to more nimbly address FWA while reducing false positives To make an obvious understatement, the new coronavirus (COVID-19) pandemic is an event like we’ve never seen. While essentially the whole country is shut down, the...
Evaluate Advanced Healthcare Fraud Solutions in 3 Questions
How can your health plan tell if a fraud solution’s claims are valid? Just in the last year, dramatic leaps forward have occurred in advanced technology, and new healthcare fraud solutions have emerged to take full advantage of these improvements. According to...
Your FWA solution may not be as modern as you think.
The package may have changed, but the truth is most FWA solutions are still relying on legacy technology. 3 ways to spot the difference. To prepare for the advancing disruptions to healthcare, most plans we speak with have made some progress towards digital...
No, Healthcare Can’t Pursue Fraud like Credit Card Companies. Here’s Why.
For consumers, the credit card fraud prevention experience is seamless, which leaves many health payers wondering why they can’t access the same technology. The short answer? It’s complicated. It’s easy to see how health payers, who have become disenchanted with...
Press Release: Leading Payment Integrity Technology Company Launches New Solution to Combat FWA
ClarisHealth VP of Program Integrity Mark Isbitts envisions a “better way” to FWA management, announces release of Pareo Fraud at 2019 NHCAA Conference NASHVILLE, Tenn., October 21, 2019 – At the annual NHCAA Anti-Fraud Training Conference in Nashville last week,...
Here’s What You Don’t Know about Fraud, Waste and Abuse
Fraud is different from Waste and Abuse, and most technology solutions don’t adequately address either issue. Think you know how to manage fraud, waste and abuse at your healthcare organization? CMS doesn’t agree. In fact, the promises of change and reform coming from...
ClarisHealth Hires Mark Isbitts as Vice President of Program Integrity
25-year industry veteran will extend ClarisHealth’s strategic direction in growing and building market-leading technology solutions for health plans. NASHVILLE, Tenn., July 2, 2019 – ClarisHealth, a leading provider of advanced payment integrity technology for health...
Lack of Documentation is a $23 Billion Overpayment Problem for Medicare
Medicare overpayment is a massive problem, and lack of documentation is a significant contributor. When we see errors adding up to billions of dollars in improper payments, we pay attention. As payment integrity technology experts and also healthcare consumers we take...
A Custom FWA Solution for Smaller Health Plans
Out-of-the-box Fraud, Waste and Abuse solutions just don’t cut it for smaller health plans. If you lead a health plan with fewer than 250k covered lives, you may think you’re out of luck when it comes to a comprehensive FWA solution. Some of the larger technology...
Prepare for CMS Audits: A Guide
Here's what to expect following new CMS payment integrity initiatives, including a guide to CMS audit protocols. The pressure is on for state-administered Medicaid programs (and the MCOs that run them). New initiatives released over the summer by CMS promise increased...
Fraud, Waste & Abuse is Not Total Payment Integrity
Don’t settle for “good enough” when a better solution exists. Fraud, waste and abuse (FWA) is a serious problem, one that can also be seriously misleading for healthcare payers looking to transform their revenue streams. That’s because many health plans mistake strong...