Preventing Fraud, Waste and Abuse: Analytics/ML/AI and Case Management
eSimplicity experts know the business operation of program integrity efforts for insurance payers, and provider, beneficiary, claims and clinical data that forms the base of evidence in the fight against healthcare fraud, waste and abuse. Our data engineers enrich and integrate the CMS data sources, including:
• Claims data (e.g., Part A, B, C, D, DME and Medicaid TMSIS),
• Clinical quality reporting data,
• Identity resolution data (e.g., provider and beneficiary), and
• Investigation sources.
Recognized as a small business vendor of choice for multiple modern data pipeline and analytics implementations, eSimplicity uses open architecture technologies (e.g. the Palantir Foundry platform or a combination of Spark, EMR, and Redshift) for agencies including the CMS, DoD, U.S. Patent office, and the oil and gas industry. Our implementation approach provides support for data lineage, enables advanced analytics and machine learning models, and supports investigators who need to drill down on 360-degree views of provider and beneficiary data and their provider network for further analysis.