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Payment Integrity

Combining AI and advanced analytics with clinical expertise.

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Remove erroneous claims at any stage.

Our Payment Integrity solutions, also known as Program Integrity, address the full range of improper payments using advanced analytics, leading technologies, and expert clinicians. Gainwell and HMS, a Gainwell Technologies company, deliver savings, compliance, and innovation for Medicaid, Medicare, commercial, and marketplace plans. We enable plans and programs to avoid and recover improper payments, detect and prevent fraud, and ensure healthcare funds are used as intended — for member care.

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$10 Billion

Total Recoveries & Savings

21+ Million

Cost Avoidance Records Delivered

4.8 Billion

Claims Processed

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.

Clinical Claim Reviews

Our Clinical Claim Reviews identify coding, location, level of service, and reimbursement errors by comparing claims against medical records — either pre- or post-pay. Operating at the intersection of AI and in-house expertise, our algorithms always improve and target the most at-risk claims.

Payment Analytics

Payment Analytics is our post-payment 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.

Eligibility Verification

Verifying eligibility is essential to preventing avoidable costs. Our Eligibility Verification solution not only manages the verification process, but also prioritizes clarity — ensuring employees know why someone is ineligible.

Pharmacy Payment Integrity

Our Pharmacy Payment Integrity tool leverages AI analytics to target high-value cases, with customization options that allow you to adhere to specific policies and regulations with ease. You also have the peace of mind that comes with staff pharmacists and nationally certified pharmacy technicians performing all clinical reviews.

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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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.

Medical professionals, two men and a woman, smile and look at clipboards in a hospital setting

Using AI in Medicaid Claim Reviews

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Medicaid Modernization: Aligning Business Strategy with Human Outcomes

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<p>Pharmacy Solutions Introduction</p>
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Pharmacy Solutions Introduction

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