Fighting fraud, waste, and abuse with proactive Payment Integrity

HMS Payment Integrity solutions reduce improper payments and fraud, waste, and abuse (FWA) through an intelligent, integrated claims workflow that elevates existing systems and delivers proactive prevention, stronger collaboration, and ongoing innovation. We drive savings, ensure compliance, and support efficiency for Medicaid, Medicare, commercial, and marketplace plans.

Our solutions span the entire claims lifecycle with advanced analytics, leading technologies, and expert clinicians. Our end-to-end approach avoids improper payments, detects and prevents fraud, and safeguards program dollars–keeping resources focused where they matter most–member care.

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FWA Suite in New Mexico

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$11 Billion

Total Recoveries and Savings

Community Engagement

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FraudCapture^®

FraudCapture® is a cloud-hosted platform that supports identifying fraud, waste, and abuse. Its intuitive, mobile-friendly software exposes issues through clear visualization and easy-to-navigate exploration tools. Additionally, it offers Special Investigative Unit (SIU) services for extra support.

Payment Analytics

Payment Analytics is our postpay data mining solution that can be customized to your needs. It uses proprietary data analysis tools to compare claims history across many criteria that client systems or claim processors often miss.

Clinical Claim Reviews

Our solution combines an exhaustive historical dataset, unparalleled clinical and data science expertise, and industry-leading analytics supported by cutting-edge machine learning technology to deliver a preeminent, comprehensive solution that ensures billing and coding accuracy.

Itemized Bill Review

Itemized Bill Review (IBR) is our audit solution that integrates itemized bill analysis, clinical chart review, and coding validation to ensure that billed services were ordered, performed, and allowable. These audits recover overpayments and support payment integrity by focusing on billing compliance, outliers, and adherence to plan policies and billing standards.

Pharmacy FWA Audit Services

This solution uses predictive analytics to detect and prevent improper payments, spanning concurrent, desk, and field audits as well as Special Investigation Unit (SIU) support.

Additional solutions making healthcare more efficient and effective.

Coordination of Benefits

Providing comprehensive and innovative third-party liability solutions.

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Care Quality

Enabling quality care and affordability with strategies that balance empathy and efficiency.

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Data & Analytics

Transforming your most complex data into actionable insights with Gainwell Genius™.

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Verification Solutions

HMS Verification Solutions ensure states verify eligibility, residency, community engagement, and dependent requirements quickly, accurately, and transparently – protecting coverage for members and their dependents who qualify and stopping waste before it starts.

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Actionable insights that
empower healthcare progress.

We’re passionate about delivering ideas that can help shape the future of
healthcare, using education and transparency to improve health outcomes for all.