Pondera Solutions
Industries

Healthcare

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

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Investigation-Ready Leads

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.

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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.

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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.

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Solutions

Pondera uses prediction algorithms and machine learning to predict, detect, and investigate fraud, waste, and abuse in healthcare and government programs.

  • FraudCaster® Read More
  • CaseTracker™ Read More
  • DataResolver® Read More
  • ID Risk Analytics Read More

By Role

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

  • For Analysts Read More
  • For Investigators Read More
  • For Managers Read More

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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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Pondera Solutions