MAC + UPIC + state Medicaid

Utilization Management Fraud Detection

Utilization management claim integrity across pre-auth approval patterns, concurrent-review concurrence, retrospective denial reversal anomalies.

The UM fraud landscape

Understanding the complexities of utilization management fraud

Utilization management (UM) fraud is a critical concern for Medicare Administrative Contractors (MACs), Utilization Program Integrity Contractors (UPICs), and state Medicaid programs. This section delves into the intricacies of UM fraud, highlighting the challenges in detecting and preventing fraudulent activities across pre-authorization, concurrent review, and retrospective denial reversals.

Utilization management fraud encompasses a range of deceptive practices aimed at manipulating the approval and review processes to gain undue benefits. These practices can lead to significant financial losses and compromise the integrity of healthcare services. Understanding the landscape of UM fraud is essential for developing effective countermeasures.

How JIL closes it

JIL Sovereign's approach to combating UM fraud

JIL Sovereign offers a comprehensive solution to address utilization management fraud through its advanced payment-integrity platform. By leveraging a robust set of attestation checks and integrating multiple data sources, JIL ensures thorough scrutiny of pre-authorization approval patterns, concurrent review concurrence, and retrospective denial reversal anomalies.

JIL's platform incorporates 16 specialized checks designed to detect UM fraud across various stages of the utilization management process. These checks are integrated into the existing four-pillar architecture, ensuring seamless operation and high detection accuracy. The platform's ability to cross-reference data from diverse sources enhances its capability to identify fraudulent activities effectively.

Pricing

Transparent and competitive pricing for UM fraud detection

JIL Sovereign provides transparent and competitive pricing for its utilization management fraud detection services. The pricing structure is designed to offer flexibility and scalability, catering to the diverse needs of MACs, UPICs, and state Medicaid programs.

Pricing -- Fraud Pillar Standard

One model. Bottom-line aligned.

Retroactive scan
one-time, scoped to volume
4-year minimum lookback. Builds the base dataset. Proves the closed-loop economics before the flat-fee leg starts.
Flat fee
12.5% of disclosed PI spend
Annual, capped. Covers nightly T1 + AVA + T2 + CREB(TM) generation. Below the industry-standard 15 to 25% SIU contingency.
Contingency
10% of net cash recovered
Performance-aligned. Fires only on actual recovered cash, net of MAC appeal, settlement, and pursuit. Outside counsel runs 33%.
90-day pilot
$1M all-in, asymmetric downside
If Day 90 deliverables miss, the $1M converts to a 6-month platform credit and contingency drops from 10% to 7.5%. No other vendor in PI takes pure downside on the math.

Pricing anchored to public 10-K Schedule H disclosures + CMS PERM 2024. UHG-scale case study available at /products/mco-flat-fee.

90-day pilot

Experience JIL Sovereign with a 90-day pilot program

To demonstrate the effectiveness of our UM fraud detection solution, JIL Sovereign offers a 90-day pilot program. This pilot allows potential clients to experience the platform's capabilities firsthand, ensuring they can make an informed decision based on real-world results.

During the pilot, clients will have access to the full range of UM fraud detection features, including the 16 specialized checks and integration with multiple data sources. The pilot program is an excellent opportunity to evaluate the platform's performance and its impact on fraud detection and prevention efforts.