Managing Fraud and Abuse

InvestiClaim™, the McKesson fraud and abuse management solution, helps fraud teams spot billing trends that are highly indicative of serious infractions and take action before or immediately after payment.

By pairing our clinical expertise with Fair Isaac, the leader in analytics and data mining tools, McKesson has developed a fully automated detection and analysis management solution that meets payors’ business needs and time-sensitive operational requirements. McKesson adds the important layer of expert clinical analytics – alerts that help discern highly suspect activities from expected behaviors based on clinical attributes.

InvestiClaim delivers expert fraud and abuse detection, analytic and case management tools via a convenient, easy-to-use web-based model. The solution’s unique clinical alerts provide pre-pay or fast-cycle post-payment identification of aberrances and trends in the claim data, through its sophisticated scoring methodology that elevates and highlights the most probably cases. This clear, identification of suspect claims significantly reduces “false positive” leads, letting plans focus resources on critical investigations.

Wide-Ranging Benefits

• Improved, Proactive Detection
  InvestiClaim uses the McKesson clinical alerts to identify leading scenarios of unwarranted billing at the forefront of the claim workflow. The solution’s predictive analytics scores for aberrance, and displays the results through the web so users can quickly take action on high scoring encounters.
  
  
• Build Effective, Defendable Cases
  Electronic case management tools, built into InvestiClaim, help consolidate and manage evidential data and investigation activities to build solid, defensible cases.
  
  
• Streamline and Automate Investigations
  The system makes it easy to log and track daily events, case notes and status. With accurate, timely records, investigators can easily compile and share information to streamline work administration.
  
  
• Document the Savings
  Advanced analytic capabilities greatly increase preventable dollars saved. InvestiClaim helps users identify and document saved benefit dollars stemming from unwarranted claim submissions.