Pondera’s system provides payment integrity services through pre-payment and post-payment analytics on providers, beneficiaries, claims, and members for both fee-for-service and managed care organizations
All aspects of Pondera’s system are built to handle the massive data sets found in healthcare including smart link charts to view large networks of providers and beneficiaries/members, and scorecards to triage leads and prioritize enforcement activities.
Pondera combines hundreds of healthcare-specific detection algorithms to identify issues such as doctor shopping for opioids, duplicate payments, unbundling, up-coding, unnecessary procedures, and unusual travel patterns. Designed to avoid provider abrasion but ensure effective program oversight, Pondera’s Special Investigations Unit helps design and tune the algorithms and brings context to the analytics, enabling your auditors and investigators to understand the reasons behind an alert or fraud risk score.
Managed Care and Fee for Service
Pondera is used in both managed care and fee-for-service programs including Medicaid, Medicare, and commercial markets with specialized detection models for healthcare programs. This includes functionality for eligibility validation, provider analysis, and suspicious claims/encounter detection.
Pre- and Post-Payment Analytics
Pondera can be used for both pre-payment and post-payment program integrity enforcement. The system can flag and score improper claims before they are made allowing you to suspend or deny payment. It can also be used post-payment as a detection, investigation, and enforcement system including fully integrated case management functionality.
Beneficiary and Provider Validation
Pondera can help you validate both beneficiaries/members and providers using third-party data, applicant data, and ongoing behavioral analysis. This can help you identify and stop bad actors at the “front door” and those program participants who begin to violate program policies after being enrolled in the program.
Opioid Monitoring and Management
Pondera has specific algorithms, third-party data matching services, and geospatial and link analysis functionality to help you detect individual instances of doctor shopping and drug diversion schemes. In addition, the system can be used to identify more collusive types of schemes including referral and kick-back schemes and trends, patterns, and clusters of suspicious activities relating to opioid prescribing and use.
Modern Surveillance and Utilization Review Subsystem
Pondera’s complete solution can form the backbone of your Surveillance and Utilization Review (SURS) solution. With pre and post payment surveillance, provider and beneficiary/member review, and a full array of analytics and third party data to augment your claims and encounter data, the Pondera solution provides cutting-edge Fraud, Waste and Abuse monitoring. Reporting capabilities include random sampling, standard deviation from the norm, and more.
Program data and 3rd party data are ingested and run through procedural and prediction models to detect previously known and unknown bad actors, schemes, and patterns. Data is vetted prior to analysis with our proprietary data profiler tool and assessed for completeness, efficacy, consistency, and usefulness.
Fully-integrated investigative case management imports cases from the fraud detection module or other sources and uses workflow and rules engines to route cases through your resolution process. The mobile application allows field investigators to review, record, and track cases while in the field.