Fraud, waste, and abuse detection and prevention


Fraud, waste, and abuse detection and prevention

Fraud, waste, and abuse detection and prevention

Proven fraud, waste, and abuse detection and prevention

Proven fraud, waste, and abuse detection and prevention

State Medicaid agencies must provide adequate oversight of the dollars they spend for healthcare, whether those dollars are spent on fee-for-service claims, managed care plans, or through new and evolving value-based payment programs. Offering broad-based expertise, Cognosante helps states effectively and efficiently oversee their Medicaid dollars to ensure both program and fiscal integrity using our eSante® Analytics tools to maintain program integrity; minimize fraud, waste, and abuse vulnerabilities; and comply with new Centers for Medicare & Medicaid Services (CMS) regulations.

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Cognosante has:

  • Assisted more than 40 Medicaid programs in procuring Surveillance and Utilization Review Subsystems (SURS), Medicaid Management Information Systems (MMIS), program integrity, and fiscal agent services
  • Developed the initial Medicaid Information Technology Architecture (MITA) Framework for CMS, illustrating a deep knowledge of national program integrity operations and systems
  • Better served our customers through strong utilization review services, such as hospital preadmission and discharge review
  • Served as a Medicaid Integrity Contractor for CMS, as well as a state Medicaid Recovery Audit Contractor since 2011, performing automated and complex reviews of claims, auditing managed care encounters, conducting credit balance transfer audits, and performing analytics on claims and other data to identify potential fraud, waste, and abuse

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