Program Integrity

Case Management

Analytics to Identify

Providers or Claims for

ReviewRetrospective Claims Editing

to Identify Overpayments

Claims Auditing

Overpayment Recovery

Provider Education

Feedback to Policies and

Systems

Investigate Fraud

Referrals

Medicaid Audit Lifecycle

3

How can Program Integrity staff effectively manage audit findings, recoveries, and provider communication?

Challenge

eSante™ ARMS™ allows organizations to: • Automate investigations

• Analyze multiple data sources with cross-dimensional analytics and rich visualization tools

• Create repeatable, auditable, defensible and recoverable investigative processes

• Control access to and custody of sensitive information

• Customize dashboards for different stakeholder roles

• Publish findings that comply with legal, regulatory and industry reporting standards

• Reduce time and cost of investigations

Supports All Program Integrity Business Processes

5

Identify Vulnerabilities

• Review claims• Analyze patterns• Identify schemes• Detect Transactions• Estimate exposure• Probe weaknesses

Evaluate Workload

• Approve pursuits• Determine/apply threshold

• Determine extrapolation, sampling

Conduct Remediation

• Assign investigation cases

• Audit cases• Enforce compliance

Manage Recoveries

•Generate demand letters

•Reconcile remittance

•Update A/R

Process Appeals

•Log appeal•Resolve appeal

Fully Modeled

Investigation Command & Control

Results: • Rapid identification and

processing of improper payments

• Better understanding of cause for improper payments

• Up-to-date/quality provider data

• Streamlined communications to providers and payer agencies

Reports

Workflow

Better organized

• Suspected fraud cases well documented and qualified

Demonstration

•Dashboard of Case Activity

•Review Case

•Attach chart

•Recovery

•RAC Reports