HEALTHCARE


Pondera’s system provides pre-payment and post-payment analytics on providers, pharmacies, beneficiaries, members, and claims for both fee-for-service and managed care organizations


Investigation-ready leads

Pondera’s system provides pre-payment and post-payment analytics on providers, pharmacies, beneficiaries, members, and claims for both fee-for-service and managed care organizations. All aspects of the system are built to handle the massive data sets found in healthcare including smart link charts to view large networks of providers and beneficiaries, 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. 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.

Learn more about FraudCaster® and CaseTracker™


Managed Care and Fee for Service

Pondera is used in both managed care and fee-for-service programs with specialized detection models for both 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 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 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.


Your Role

Discover how analysts, investigators, and managers leverage Pondera’s system to improve efficiency and deliver results.

For Analysts

For Analysts

Pondera gives analysts the ability to view comprehensive program data, matched against third party data sources, and run through a series of procedural and predictive models.

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For Investigators

For Investigators

Pondera helps investigators, both in the field and in the office, to streamline workflows and easily track cases through cloud integration.

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For Managers

For Managers

Pondera’s CaseTracker™ allows managers to easily track and manage cases and case files, review detailed team performance metrics, and manage workflow through to case resolution.

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Solutions

Pondera ingests your program data, matches it against third party data sources, and then runs it through a series of procedural and prediction models to detect previously known and unknown anomalies and patterns.

FraudCaster®

FraudCaster®

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.

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CaseTracker™

CaseTracker™

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.

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DataResolver®

DataResolver®

Pondera analyzes the fitness of your data specifically for its use in fraud detection analytics. This includes completeness, referential integrity, usability, and stability to identify specific problems in client and third-party source data.

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Our industry experts are happy to provide an in-person or web conference overview that is customized to your organization and your needs.

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