Improper payments in US Healthcare programs are estimated at over $200 billion annually

The challenges organizations are facing are caused by a lack of a true single view of all the data that exists, resulting in:

  1. Fraudulent providers re-enrolling repeatedly with slight variations of their data.
  2. Phantom providers billing for services that they haven’t provided using stolen patient data.
  3. Poor pre-payment screening, resulting in claims being paid without risk assessment.

Put an end to improper activity in Healthcare by leveraging AI and machine learning to deliver results at scale

  1. Effectively connect all internal and external data (such as CMS Adverse Actions Report, NPI registry, etc.) into a single view using Entity Resolution.
  2. Understand the broader context by revealing seemingly unlikely connections with Network Generation.
  3. Detect potentially fraudulent behavior automatically for review, with advanced data modeling and scoring capabilities.
  4. Investigate quickly with a UI that visualizes relevant connections and risk factors of every provider and every claim.
90
%
increase in accuracy
66
bn
scale to over 66bn records

Using Data and Analytics for Intelligent Healthcare Integrity Solutions

The key to overcoming Healthcare onboarding and payment integrity challenges lies in the ability to unlock the value of data and see the wider context.

AI/ML and analytics will have a big impact in Healthcare IT and must be adopted not only for disease prevention and diagnosis, but also for automating complex processes to improve patient care outcomes.

Find out how you can overcome challenges and understand the necessary steps required to become a truly data-driven organization.

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Enable your organization with contextual decisioning capabilities

1

2

3

Screen

your providers and claims with the highest accuracy possible, using data from multiple data sources.

2

Continuously monitor

and get alerted about updated information for eligibility and compliance, automatically highlighting new or changing risks associated with a provider or claim.

3

Analyze

 to identify risky providers and highlight potential fraud, waste, and abuse through a visual UI, uncovering the risk factors identified.

Use the platform for Contextual Decision Intelligence

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How can Quantexa’s Healthcare solutions help your organization?

A single source of truth of providers, suppliers, and claims across both internal and external data.

Reduction of improper payments through a real-time multi-dimensional view of claims, providers, and beneficiaries.

The ability to see discrepancies between data in various systems (NPI directory vs. business records) to solve data problems.

Robust risk assessment capabilities that uncover hidden risks using AI.

Why use the Quantexa platform

Build once, use many, ingest to create a single view with networks

Apply your data to multiple use cases—without replicating data sets.

Speed time-to-value

Operationalize your data in a matter of months – not years.

Scale to tens of billions of records in batch or real time

Built on proven, scalable open source technologies like Hadoop, Spark and Elastic.

Future-proofed open architecture

Integrate seamlessly into your existing IT ecosystem, with flexible deployment options: native, or containerized for private and public cloud.

Make faster, more accurate decisions

Use context to improve decision accuracy across the organization, find new opportunities and uncover risk.

Keep your data secure

Rely on granular security levels for dynamic control, with all activity audited.

Ensure data transparency

Use explainable data linking, advanced AI and decision models for regulatory compliance.

Overcome data quality issues

Use entity resolution and data volume to overcome missing or poor quality data.

Book a demo

See how our Contextual Decision Intelligence platform prevents fraud before it happens, creates a real-time view of your customers, and reduces false positives.