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Payors and TPAs face persistent exposure to fraud, waste, abuse, and improper billing across high-volume claims environments where utilization patterns can be difficult to detect through static reporting alone.
The client needed a stronger way to identify improper billing and suspicious provider utilization patterns across claims, providers, members, services, measures, and registries.
Program integrity teams required analytics that could combine data from varied sources, surface outliers, and trigger cases for desktop or onsite audits of providers and members.
Improper billings created payment leakage, higher operating cost, and reduced visibility into emerging fraud patterns.
With payor leaders under pressure to protect claims spend, improve cash flow, and increase program agility, the client needed an AI-driven utilization analytics solution that could detect known and new risk patterns at scale.
Novacis Digital delivered FWA and Utilization Analytics, a purpose-built payor claims integrity solution built on eCareVantage Payer Analytics.
The solution combined Surveillance and Utilization Review (SUR) dashboards with the Fraud and Abuse Detection System (FADS) to detect improper billing and suspicious utilization patterns across claims, providers, patients, measures, and registries.
SUR used descriptive statistical techniques for utilization outlier detection, while FADS applied AI-driven analytics and machine learning to identify complex and emerging fraud patterns.
Unlike generic claims reporting, the solution connected pre-built analytics models, measure profiles, pattern processing, registries, dashboards, and case management integration into one governed claims integrity layer.
User management, security controls, configurable business models, and audit-ready case outputs supported accountable review workflows.
This shifted the operating model from retrospective utilization review to analytics-led claims integrity and case prioritization.
Payor Utilization Capabilities
Claims Integrity Features
Novacis Digital delivered eCareVantage Payer Analytics in record time as a secure cloud-based analytics solution for payor utilization and FWA detection.
The rollout gave program integrity teams access to SUR dashboards, FADS analytics, claims and provider registries, pattern processing, measure dashboards, performance benchmarking, and case management integration.
Early adoption improved improper billing detection, reduced operating cost, strengthened cash flow, and increased visibility into program activity.
The results directly addressed the need to protect claims spend, identify new fraud patterns, and help audit teams prioritize desktop or onsite investigations.
Prevented 5–10% of improper claim billings, protecting $10M–$20M in potential exposure across $200M of reviewed claims.
Reduced operating costs by 15%, lowering the effort required to identify outliers, review utilization, and prepare FWA cases.
Improved claims integrity by identifying newer fraud schemes and helping payors respond before patterns became recurring leakage.
Delivered integrated coverage across claims, providers, patients, registries, measure profiles, pattern processing, dashboards, and case management tools.
Improved audit execution by routing suspicious utilization patterns into case workflows for desktop or onsite provider and member reviews.
