Cost Containment & Care Quality

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For your state agency and managed care organizations to run at peak efficiency with minimal waste, you need three basic things. Coordination of Benefits (COB) ensures that you pay only claims that you are responsible for. Payment Integrity (PI), also known as Program Integrity, makes sure that Fraud, Waste and Abuse (FWA) are under tight control, and that claims are medically necessary and correctly submitted. Care quality ensures strategies and services are in place to improve care and reduce costs for members with the highest degree of need.

Gainwell has the experience and the solutions you need to keep your programs running efficiently, without impacting quality of care for your recipients.

Why Cost Containment & Care Quality?

Gain greater accuracy

Shut down fraudsters

Streamline processes with built-in compliance

How We Can Help

We pioneered Coordination of Benefits in 1985, when we saw that Medicaid was paying billions of dollars that it shouldn’t. And today, our COB solutions for Medicaid, Medicare, Military, State Agency programs and MCOs are the best, most innovative available. No one else can come close to our proprietary data and algorithms.

Our PI solutions root out claims that are erroneous for any reason, at any stage in the claim cycle. We identify incorrect claims before or after payment. If post-payment, we have robust recovery systems in place to get the money back into your account. We can even spot bad claims without medical records from the provider, reducing abrasion and speeding recovery. Machine learning and artificial intelligence (AI) are continually making our solutions smarter and more automated, but when a human touch is needed, our people are the best and most experienced in the business.

Our advanced care management ecosystem puts personalized, data-driven and actionable care plans at your fingertips, reducing inefficiencies and empowering your teams to focus on what’s important – caring for those who need it most.

Coordination of Benefits

Pre-payment Solutions

Cost avoidance beats pay-and-chase. Our end-to-end COB solutions focus on speed to delivery, and data quality and accuracy to create actionable insights. This, combined with our unique market expertise, ensures maximum cost avoidance for your plan.

Post-payment Recovery

Already paid that claim? No problem. We examine improperly paid claims using artificial intelligence and machine learning to select the best candidates for recovery. Then we pursue those recoveries using efficient electronic processes to maximize savings.

Case Management

Our Case Management solution makes sense of scattered, disorganized data, and drives cases to reimbursement and closure. We deliver secure, reliable, web-based access around the clock, with real-time updates, document imaging and a guided workflow. Our case managers and attorneys are unmatched when it comes to complex, high-dollar cases.

Payment Integrity

Clinical Claim Reviews

Our Clinical Claim Reviews identify coding, location, level of service and reimbursement errors by comparing claims against medical records, either pre-pay or post-pay. Driven by synergy between artificial intelligence and clinical experts, our battle-tested and constantly improving algorithms target claims most likely to have errors.

Payment Analytics

Payment Analytics is a customizable post-payment data mining solution that uses exclusive data analysis to compare claims history against specific billing, coding, utilization and reimbursement rules that client systems or claim processors might miss.

FraudCapture®

FraudCapture is a modular, cloud-hosted platform that provides end-to-end support in the identification of fraud, waste and abuse. Beneficial to operations of all sizes, our intuitive, mobile-friendly software exposes issues through clear data visualization and easy-to-use data exploration tools.

Pharmacy Payment Integrity

Our Pharmacy Payment Integrity solution uses AI-driven analytics to target high-value cases for review. Customization to specific policies and regulations is easy, and clinical reviews are performed by staff pharmacists and nationally certified pharmacy technicians.

Eligibility Verification

Better cost prevention also means better compliance. Many employers and states are accruing high financial costs from those who don't meet their eligibility criteria, creating the need to verify eligibility more than ever. Our Eligibility Verification solution handles verifications with sensitivity, ensuring employees understand exactly why someone may be ineligible, and explaining the process every step of the way.

Utilization Management

Utilization Management addresses the most pressing needs of state Medicaid programs by combining cost management with accurate pre- and post-payment claim reviews and prior authorization from our Clinical Care Reviews.

Care Management

Our interoperable Care Management platform is built on a solid foundation of automation, standardization and mature processes. Utilizing data from proven, industry-standard COTS products such as the Johns Hopkins ACG System and administrative and clinical information, our service improves quality and reduces the total cost of care.

We can help. But the next move is yours!

Please fill out the information below to start a no-pressure chat with one of our knowledgeable solutions experts.

Additional Insights

TRICARE and Medicaid Coordination of Benefits: The System is Broken
Generate Pre-Payment Claim Review Savings by Aligning Payer & Provider Incentives
How Pre-Payment Integrity Can Incentivize Evidence-Based Care
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