Program Integrity

Compliance and the Reduction of Improper Payment, Fraud, Waste and Abuse

Better Care and Smarter Spending

With a focus on driving out waste and fraud, Alliant helps to recover claims dollars through our program integrity services. We provide efficient and consistent medical reviews and audits using our proprietary MedGuard® system, enabling us to quickly identify, recover, and prevent inappropriate payments for health care. MedGuard® functions include detecting, investigating, and preventing fraud, waste, and abuse by health plan participants. With MedGuard®, we are able to analyze claims and payment data using statistical and database techniques that look for patterns to suggest fraud or abuse. We serve health insurance plans, health care providers, and federal and state based health programs (Medicare, Medicaid). All stakeholders in the health care delivery continuum have an incentive to identify and prevent fraud, waste, and abuse within the healthcare system.

Our Services:

  • Data analysis / target identification
  • Desktop review
  • Onsite compliance and medical review
  • Surveillance and Utilization Review Subsystem (SURS) Reviews
  • Provider / member profiling
  • DRG & coding review and consultation
  • Focused studies
  • Claims review
  • Prepayment review
  • Payment error rate review and analysis

The Alliant Value:

  • Focus on large problems and patterns of potential problems, not just one incident
  • We can recommend best practices to avoid fraud and abuse
  • With MedGuard®, you never have to wonder if an honest mistake is costing you money or if you have an integrity problem
  • To prevent future overpayments, Alliant’s program integrity services include provider education on proper billing practices to effect a reduction of improper payments over time
  • Accurate, defensible findings ensure an improved recovery rate
  • Gain access to the information and data needed for program decision-making