Cognosante: Program Integrity Case Management Presentation

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1. Program IntegrityCase Management 2. Analyticsto Identify Providers orClaims forReview RetrospectiveInvestigate Claims Editing Fraud to Identify Referrals Overpayments Medicaid AuditFeedback toLifecycleClaimsPolicies and Auditing SystemsProviderOverpayment Education Recovery 3. ChallengeHow can Program Integrity staff effectively manage auditfindings, recoveries, and provider communication? 3 4. eSante ARMS allows organizations to: Automate investigations Analyze multiple data sources with cross-dimensionalanalytics and rich visualization tools Create repeatable, auditable, defensibleand recoverable investigative processes Control access to and custody ofsensitive information Customize dashboards for differentstakeholder roles Publish findings that comply with legal,regulatory and industry reporting standards Reduce time and cost of investigations 5. Supports All Program Integrity Business ProcessesIdentifyEvaluateConduct Manage Process AppealsVulnerabilities WorkloadRemediation Recoveries Review claims Approve pursuits Assign investigationGenerateLog appeal Analyze patternsDetermine/apply casesdemand lettersResolve appeal Identify schemes thresholdAudit cases Reconcile Detect Transactions DetermineEnforceremittance Estimate exposureextrapolation,compliance samplingUpdate A/R Probe weaknesses5 6. Fully Modeled 7. Investigation Command & Control 8. Results: Rapid identification and processingof improper payments Better understanding of cause forimproper payments Up-to-date/quality provider data Streamlined communications toproviders and payer agencies- Reports- Workflow- Better organized Suspected fraud cases welldocumented and qualified 9. DemonstrationDashboard of Case ActivityReview CaseAttach chartRecoveryRAC Reports