CERIS Announces Enhanced Offering to Fraud, Waste, and Abuse Solutions

Rhea-AI Summary

CERIS, a CorVel Company, has announced enhancements to its Fraud, Waste, and Abuse (FWA) solutions. The improvements include earlier detection capabilities and improved behavioral analytics. Key features of the enhanced offering are:

• Fraud Case Analytics with machine learning capabilities
• Fraud Scanners for pre- and post-pay claims
• Flexible Fraud Dashboard & Reporting
• FWA Consulting services

Over the past year, CERIS analyzed 1.1 billion claims, flagging 1.6 million as questionable and uncovering $700 million in suspicious medical billing. The company aims to support various sectors, including workers' compensation, government payments, and group health, in preventing and mitigating fraud across organizations.

Positive

• Enhanced FWA solutions with earlier detection capabilities and improved behavioral analytics
• Analyzed 1.1 billion claims in the past year, uncovering $700 million in suspicious medical billing
• Expansion of services to cover workers' compensation, government payments, and group health sectors

Negative

• None.

Insights

Healthcare Technology Expert

CERIS's enhanced Fraud, Waste and Abuse (FWA) solutions represent a significant leap forward in healthcare payment integrity. The integration of advanced behavioral analytics and earlier detection capabilities addresses a critical need in the industry. With the NHCAA estimating annual losses in the tens of billions, these improvements could substantially impact healthcare organizations' bottom lines.

The most intriguing aspect is the use of machine learning for rapid analysis of case data. This technology can potentially uncover complex fraud patterns that traditional methods might miss. Additionally, the focus on claims under $500 is astute, as these often fly under the radar but cumulatively represent a significant fraud risk.

However, the true test will be in the implementation. The success of these tools will depend on their ability to minimize false positives while maximizing genuine fraud detection. Healthcare organizations should closely monitor the performance metrics of these enhanced solutions to ensure they're delivering on their promise.

Financial Analyst

CERIS's enhanced FWA solutions could have a positive impact on CorVel's financial performance. The healthcare payment integrity market is growing and this move positions CERIS to capture a larger share. Key financial implications include:

• Potential for increased revenue through expanded service offerings
• Improved client retention due to more comprehensive FWA solutions
• Possible margin expansion if the automated tools prove cost-effective

The revelation that CERIS analyzed over 1.1 billion claims in the past year, flagging 1.6 million for questioning, demonstrates the scale of their operations. The $700 million in suspicious billing uncovered represents significant potential savings for clients, which could drive demand for CERIS's services.

Investors should watch for indicators of adoption rates and the impact on CorVel's revenue and margins in upcoming quarterly reports to gauge the success of this enhanced offering.

FORT WORTH, Texas, Aug. 27, 2024 (GLOBE NEWSWIRE) -- Today, CERIS, a CorVel Company, has announced advancements to its current Fraud, Waste, and Abuse (FWA) solutions, including earlier detection capabilities and improved behavioral analytics. These new integrations and services will expand on CERIS’ current FWA offering for customers as they navigate a complex healthcare industry and work to better manage and mitigate prevalent fraud and risk issues in today’s landscape. Through identity and behavioral analytics, scanners, dashboards, reporting, and FWA consulting, CERIS’ enhanced solutions are automating detection and errors in billing to aid payers in prevention and remediation.

The National Health Care Anti-Fraud Association (NHCAA) estimates that financial losses for healthcare organizations are in the tens of billions of dollars each year. A leader in payment integrity, CERIS works closely with providers to overcome challenges and false payment methods through its FWA products. Today’s enhancements will support the following:

• Fraud Case Analytics - SIU and Suspicious Activity Lead Services: Case data analytics will utilize client and industry data for rapid analysis and reporting through machine learning capabilities
• Fraud Scanners: A suite of data scanners will detect suspicious activity on pre- and post-pay claims offering clients lead detection for Fraud, Waste & Abuse
• Fraud Dashboard & Reporting: CERIS will offer flexible reporting options on client analysis and results through industry standard tools
• FWA Consulting: CERIS will bring its expertise in prevention, remediation, and operational efficiencies of payment processing in support of Fraud, Waste & Abuse management

“With today’s new advancements across FWA, CERIS is excited to support the entire enterprise, from workers’ compensation, government payments to group health, and beyond,” said Mark Johnson, Senior Vice President, Product Development at CERIS. “These enhancements will automate fraud, waste, and abuse detection within claims data through solutions that are completely customizable for CERIS customers. We are able to bring in disparate data sets – across medical claims and beyond –for customers who are eager and committed to preventing fraud across their organization.”

Over the past twelve months, CERIS analyzed over 1.1 billion claims, and from this set, 1.6 million of the claims were flagged as open to questioning, uncovering more than $700 million in suspicious medical billing via CERIS’ behavioral intelligence analytics solution. The results also showed that claims under $500 are a major source of fraud and often go undetected. More details can be found in CERIS’ recent case study. The study has also allowed CERIS to develop different categories of risk to help prioritize investigations for its clients.

“At CERIS, we are committed to ensuring the proper practices are followed in the healthcare industry and that payers are aware of any suspicious actors deemed unethical. That is why we are proud to announce today’s enhancements to our FWA offering,” said Debra Hamer, Director of Product Management for Healthcare Fraud, Waste, and Abuse at CERIS. “These improvements will allow our team to enable and foster responsibility for fraud protection across the healthcare industry.”

About CERIS
CERIS, a leader in both prospective and retrospective claims review and repricing, combines clinical expertise and cost containment solutions to ensure accuracy and transparency in healthcare payments. Accuracy and validation services include itemization review, DRG validation, facility repricing, contract and policy applications, review of implants and devices, and primary payer cost avoidance. Its universal chargemaster contains billions of charge items from more than 97% of the nation’s hospitals, helping to ensure the accuracy and objectivity of each claim review.

Safe Harbor Statement under the Private Securities Litigation Reform Act of 1995
All statements included in this press release, other than statements or characterizations of historical fact, are forward-looking statements. These forward-looking statements are based on the Company’s current expectations, estimates, and projections about the Company, management’s beliefs, certain assumptions made by the Company, and events beyond the Company’s control, all of which are subject to change. Such forward-looking statements include, but are not limited to, statements relating to the Company’s payment review services and the Company’s continued investment in these and other innovative technologies, and statements relating to the Company’s service offerings. These forward-looking statements are not guarantees of future results and are subject to risks, uncertainties, and assumptions that could cause the Company’s actual results to differ materially and adversely from those expressed in any forward-looking statement, including the risk that the impact of the COVID-19 pandemic on our business, results of operations and financial condition is greater than our initial assessment.

The risks and uncertainties referred to above include but are not limited to factors described in this press release and the Company’s filings with the Securities and Exchange Commission, including but not limited to “Risk Factors” in the Company’s Annual Report on Form 10-K for the year ended March 31, 2024, and the Company’s Quarterly Report on Form 10-Q for the quarters ended September 30, 2023, December 31, 2023 and June 30, 2024. The forward-looking statements in this press release speak only as of the date they are made. The Company undertakes no obligation to revise or update publicly any forward-looking statement for any reason.

Contact: Melissa Storan
Phone: 949-851-1473
www.ceris.com

FAQ

What new features has CERIS added to its Fraud, Waste, and Abuse (FWA) solutions?

CERIS has added Fraud Case Analytics with machine learning, Fraud Scanners for pre- and post-pay claims, flexible Fraud Dashboard & Reporting, and FWA Consulting services to enhance its FWA solutions.

How many claims did CERIS analyze in the past year, and what was the result?

CERIS analyzed over 1.1 billion claims in the past year, flagging 1.6 million as questionable and uncovering more than $700 million in suspicious medical billing.

What sectors does CERIS aim to support with its enhanced FWA solutions?

CERIS aims to support various sectors including workers' compensation, government payments, and group health with its enhanced FWA solutions.

What is the estimated annual financial loss for healthcare organizations due to fraud, according to NHCAA?

According to the National Health Care Anti-Fraud Association (NHCAA), the estimated annual financial losses for healthcare organizations due to fraud are in the tens of billions of dollars.