Fraud, Waste, and Abuse Protection Improves Claims Payment Accuracy and Saves Enterprise-wide Costs
“Healthcare fraud, waste and abuse (FWA) costs the insurance industry and government programs tens of billions of dollars each year, making it essential for payers to identify potential fraud situations prior to adjudication or audits.” —Context4Healthcare
As the ACA has helped to increase the number of insured Americans, healthcare payers are discovering that systemic fraud, waste, and abuse (FWA) is growing as well, costing tens of billions of dollars annually. Detecting, correcting, and preventing FWA is a growing priority for payers, and growing numbers of payers are successfully leveraging PLEXIS’ FWA solution.
PLEXIS’ best-of-breed FWA solution accelerates adjudication and increases payment integrity. By empowering payers to analyze critical data, PLEXIS’ FWA solution recovers significant savings, increases efficiencies, and ensures regulatory compliance.
PLEXIS’ FWA solution empowers payers to:
- Reduce claim errors
- Reduce expenses and manual intervention
- Meet cost containment objectives
- Powerful payment integrity solutions
- Detect potential fraud, waste, and abuse before claim payment
- Increase auto-adjudication rates, claims payment accuracy, and regulatory compliance
- Maintain the highest level of claim compliance
- Shorten and streamline investigations
PLEXIS’ FWA solution enables the greatest cost savings and FWA reduction
PLEXIS’ FWA solution is fully-customizable to meet specific billing guidelines for institutional and professional claims, significantly reducing FWA, as well as incorporating National Correct Coding Initiative (NCCI) data rules. The PLEXIS platform performs real-time call-outs for uninterrupted adjudication. The FWA solution evaluates the claim not only for abusive billing patterns but also identifies claims that may involve third-party liability/coordination of benefits, case management opportunities, physician billing education, and many other cost recovery reports. End-users can configure responses to different types of edits, allowing them to create more efficient workflows. The extensive rule repository, advanced algorithms, and the closed loop analysis effectively optimize payer business processes for the greatest cost savings and FWA reduction.
As an integrated clinical, financial, and administrative payer platform, the PLEXIS platform is the premier claims adjudication and benefit administration software solution on the market. Serving all major healthcare payers for the past 20 years, PLEXIS simplifies and automates claims processing operations.
Learn more about our rules-based core administration + claims management solution, our suite of readily-configured business apps, and the cutting-edge services we offer as part of our full-service platform solution.