FAQ

Healthcare Fraud Shield provides AI-powered SaaS solutions that detect and prevent healthcare fraud, waste, abuse, and error (FWAE) across the claims lifecycle. Our modular platform delivers real-time and retrospective insights, empowering payers to protect dollars before they’re lost.

HCFS reduces fraud, waste, abuse, and error through a layered approach that spans the entire claims lifecycle. Our HCFSPlatform uses proprietary AI models, NLP, machine learning, and expert-built rules to detect suspicious activity across medical, pharmacy, and provider claims. We identify risks before payment to prevent losses, apply retrospective analytics to uncover overpayments, and support investigative teams with evidence-rich leads and case management tools. This end-to-end strategy helps clients reduce false positives, accelerate reviews, increase recoveries, and drive measurable savings.

The HCFSPlatform is purpose-built for fraud, waste, abuse, and error (FWAE) detection across the claims lifecycle. Unlike legacy vendors or generic analytics tools, our platform stands out for its:

• • Seamless integration across payment integrity workflows
  • Real-time protection before and after payment
  • Modular design that scales with your needs
  • Proprietary AI, NLG, and rules developed specifically for FWAE
  • Precision-tuned models that reduce false positives and maximize impact
  • Proven ROI, from 3:1 up to 20:1 depending on deployment

With HCFS, you are not getting generic business intelligence dashboards. You are getting a platform built by FWAE experts, for FWAE experts.

HCFS delivers more than just a software platform. We become a true extension of your fraud-fighting team. Clients consistently cite our exceptional support and long-term partnership model as key differentiators. We provide:

• • Dedicated access to clinical, coding, investigative, and data science experts

  • Tailored rule and model development based on plan-specific risks

  • Proactive insights and continuous platform enhancements

  • Quarterly reviews and roadmap planning

  • Ongoing training and best practice sharing

You are not just licensing technology. You are gaining a partner committed to your success.

While in-house solutions may seem cost-effective at first, they often fall short in key areas:

• • Time to Value: Building and maintaining in-house fraud tools can take years. HCFS delivers measurable results in weeks.
  • Expertise: Our platform is built by clinical coders, data scientists, and fraud investigators with deep, specialized experience.
  • Adaptability: HCFS continuously updates rules, AI models, and NLP to stay ahead of fast-evolving fraud schemes.
  • Cost and Scale: In-house tools are costly to build and hard to scale. HCFS offers a modular solution without technical debt.
  • Proven ROI: Clients see 3:1 to 10:1 ROI through high lead quality and prepay intervention—outperforming most internal tools.

Most importantly, working with HCFS allows your teams to focus on action, not infrastructure.

HCFS continuously enhances our platform by adding new rules, AI models, and detection modules based on emerging fraud trends and client feedback. Our in-house experts work closely with clients to prioritize updates that reflect evolving schemes, regulatory changes, and unique plan requirements. With a library of over 2,000 proven alerts (and growing) the HCFSPlatform stays relevant, responsive, and results-driven.

HCFS integrates more than 80 public records data sources to enrich claims-based detection with real-time, contextual insights. This helps uncover hidden relationships, verify identities, and support stronger case development. Your SIU team gets a more complete picture to prevent and investigate fraud.

PreShield flags high-risk claims, providers, members, and groups before payment using advanced AI, rules, and anomaly detection. It provides real-time alerts that help you avoid improper payments, without delaying clean claims.

PostShield scans finalized claims using layered analytics and models to uncover missed savings opportunities. It supports payment integrity, auditing, and recovery efforts with granular evidence and transparency.

RxShield specializes in identifying outlier prescribing, drug diversion, refill abuse, and misaligned billing patterns. It’s tuned to uncover pharmacy fraud in real time with embedded formulary intelligence.

AIShield delivers explainable AI and machine learning for fraud detection. It uncovers complex, evolving schemes and offers risk scores and rationale—building trust with compliance teams and investigators.

CaseShield is a secure, integrated case management system designed specifically for healthcare fraud teams. It links directly with flagged leads, investigative notes, provider profiles, and Shared Analytics.

Shared Analytics allows clients to view near real-time anonymized insights across health plans, improving scheme detection, provider pattern analysis, and cross-plan collaboration. With insights drawn from over 91 million member lives, this collaborative data network helps clients uncover broader trends, identify emerging risks sooner, and improve investigative outcomes.

FWA360Leads delivers prioritized, high-quality fraud leads powered by AI, NLP, and expert-built rules. Each lead includes evidence and risk scoring, helping SIU and payment integrity teams focus on the most actionable cases with less noise and faster results.

Yes. Fully embedded within the HCFSPlatform, the RiskAdjustment module supports coding integrity, audit readiness, and compliant reimbursement. It uses AI to detect unsupported or upcoded HCCs, validate diagnoses across care history and prescribing data, and flag inconsistencies before payment. This helps reduce audit exposure, protect revenue, and align with value-based care goals.

Yes. The HCFSPlatform is designed to reduce provider abrasion by increasing lead precision, prioritizing only high-confidence risks, and minimizing false positives. It enables proactive, non-punitive interventions like provider education letters for lower-risk patterns, helping address issues without escalating conflict. This reduces unnecessary provider outreach and preserves trust while maintaining strong fraud prevention.

Implementation timelines vary based on the modules selected, integration scope, and customization requirements. While the process is thorough, it’s designed to ensure long-term success. Our experienced implementation team works closely with your stakeholders to streamline each phase, minimize disruption, and align with your internal priorities. Clients often highlight how smooth and well-managed the process is from start to finish.

Yes. We integrate with major claims platforms and data warehouses via API, SFTP, or custom pipelines. The HCFSPlatform is built to fit your workflow, not force a new one.

The HCFSPlatform is fully modular, allowing you to license only the components you need. You can start small and scale over time, or deploy the full platform for seamless, end-to-end fraud prevention across the claims lifecycle.

Absolutely. The HCFSPlatform scales to support national insurers, regional health plans, and Medicaid programs. ur platform handles billions of claim lines and millions of members with performance and precision.

HCFS aligns with CMS, OIG, and HIPAA regulations and is HITRUST certified to ensure the highest standards of data security and privacy. Our rules and models are regularly updated to reflect regulatory guidance and coding changes, helping clients stay audit-ready and compliant across all claim types.

Clients typically achieve a 3:1 to 10:1 ROI with the HCFSPlatform, fueled by prepay prevention, postpay recoveries, and streamlined workflows.

When paired with our SIU and payment integrity services, ROI can increase up to 20:1 thanks to enhanced lead conversion, reduced manual review hours, and accelerated fraud detection.

Yes. Tools like AuditPlus streamline Statistically Valid Random Sampling (SVRS) and medical record retrieval, simplifying payer audits.

HCFS protects client data through enterprise-grade security practices, including encryption, HITRUST certification, and detailed audit logging. Our platform is built to meet healthcare’s strictest privacy and compliance requirements, ensuring data integrity and confidentiality at every stage.

Yes. HCFS aligns with client-specific data retention, archival, and governance policies. Our platform supports configurable access, retention schedules, and export controls. This gives compliance, legal, and IT teams the oversight they need to meet regulatory obligations and internal data policies.

Yes. HCFS offers full or partial outsourcing as an add-on service to the HCFSPlatform. Our experts function as an extension of your internal team providing support with fraud detection, data mining, improper billing verification, medical record review, and case development. Clients leveraging these services often see ROI increase up to 20:1.

We offer ongoing support from clinical, coding, and investigative experts. Clients also have access to tailored rule development and training. Beyond reactive support, clients receive proactive insights, quarterly business reviews, and continuous improvement support. We are your long-term partner, not just a vendor.

Yes. HCFS is willing to partner with clients to develop custom rules, models, and dashboards based on plan-specific risks and priorities.