Health plans face billions in fraud, waste, and abuse exposure annually. Pamastay gives your SIU and program integrity teams the claims-level visibility to detect schemes before they become audit findings.
Legacy SIU tools generate noise. Your team needs signal.
Enterprise SIU platforms generate thousands of low-signal alerts. Your investigators spend more time triaging noise than investigating actual schemes—while 3-10% of healthcare spending is lost to fraud annually.
Contracted provider networks include bad actors you can't identify until claims patterns become egregious. The OIG exclusion list requires monthly checks—but reactive screening isn't enough.
High-cost DME and specialty pharmacy claims are prime fraud targets. A recent OIG audit found $22.7M in improper DMEPOS payments—72% involved miscoded place of service.
CMS, OIG, and state regulators are increasing audit frequency. The OIG Work Plan designates managed care as a priority area—you need audit-ready documentation proving active FW&A monitoring.
MUE violations, duplicate billing, and unbundling schemes drain medical loss ratio. Pre-payment detection would save millions, but you're doing post-pay recovery.
You've delegated risk to ACOs and medical groups, but lack visibility into their claims patterns. Kaiser's $556M settlement shows what happens when coding oversight fails at scale.
Modern FW&A detection that prioritizes investigator efficiency over alert volume.
ML-driven anomaly detection surfaces the schemes that matter. Provider outliers, billing pattern anomalies, and network-level fraud indicators—not noise.
Deploy your own detection rules alongside our analytics. MUE thresholds, specialty-specific flags, and custom billing pattern rules—your expertise encoded.
Risk scores for every provider in your network based on billing patterns, peer comparisons, and historical flags. Prioritize credentialing reviews and investigations.
Unified visibility across your ACO and medical group partners. See their claims patterns in real-time, flag compliance risks before they become your audit findings.
Case management built for SIU teams. Assign alerts, track investigations, document findings, and generate regulatory-ready reports from a single platform.
Complete audit trails for every detection and investigation. Export packages for CMS, OIG, state regulators, and internal compliance reviews.
Real-time intelligence from federal and state regulators.
Kaiser affiliates settled False Claims Act allegations for submitting invalid diagnosis codes. The case highlights why health plans need systematic oversight of coding practices and risk adjustment.
Read DOJ Announcement →See how Pamastay delivers high-signal alerting without enterprise complexity.