Healthcare Cost Containment
Forensic Claims Analysis & Recovery
Identify and recover improper payments, billing errors, and fraudulent claims with forensic claims analysis by board-certified physicians and certified coders. Our comprehensive review uncovers overpayments averaging $2-4M annually while preventing future payment errors.
The Cost of Improper Payments
Healthcare payers lose 3-5% of total claims payments to errors, fraud, waste, and abuse. Manual audits catch less than 1% of improper payments.
Overpayments & Billing Errors
Duplicate payments, incorrect fee schedules, and coding errors result in millions in overpayments. Manual review processes catch only a fraction of these errors.
Fraud, Waste, and Abuse
Unbundling, upcoding, and medically unnecessary services drain plan resources. Detecting sophisticated fraud schemes requires clinical and coding expertise.
Limited Audit Coverage
Manual audits review less than 1% of claims due to resource constraints. Critical overpayments and patterns go undetected, allowing ongoing losses.
Complex Recovery Process
Identifying overpayments is only half the battle. Recovery requires documentation, provider negotiation, and legal defensibility—often taking months or years.
Our Solution – Forensic Claims Analysis
Comprehensive claims review combining board-certified physicians, certified coders, and advanced analytics to identify, validate, and recover improper payments.
Clinical & Coding Expertise
Board-certified physicians and certified professional coders (CPCs) review claims for medical necessity, appropriate coding, and billing compliance. Not automated algorithms alone.
Advanced Forensic Analytics
Proprietary analytics identify payment patterns, anomalies, and potential fraud schemes. Machine learning models trained on millions of claims detect subtle indicators of improper payments.
End-to-End Recovery
Complete recovery process from identification through collection. Our team handles provider outreach, documentation, negotiation, and legal support to maximize recovery rates.
Data Analysis
Pattern identification
Clinical Review
Physician validation
Documentation
Legal defensibility
Recovery
Provider negotiation
Prevention
Process improvements
Average recovery within 6-12 months
Measurable Financial Impact
Direct ROI and cost savings across every stakeholder segment
For Health Plans & TPAs
- $2-4M average annual recovery (mid-sized health plans 100K-500K members)
- 3-5% of audited claims have recoverable overpayments
- 85%+ recovery rate on identified overpayments
- ROI typically 6-12 months (3:1 to 5:1 return on investment)
- Enhanced fraud, waste, and abuse (FWA) detection capabilities
- Reduced future overpayments through process improvements
- Better medical loss ratio (MLR) management and regulatory compliance
For Self-Funded Employers
- Direct bottom-line savings: $500K-$2M recovered annually (employers with 5K-25K employees)
- Reduced healthcare spend without cutting employee benefits
- Lower stop-loss premiums through better claim management
- Protection against provider billing errors and fraud
- No internal HR/benefits staff required for claims auditing
- Improved plan performance and cost predictability
- Employee transparency: Recovered funds offset future premium increases
For Workers' Comp & Casualty
- Medical bill review and repricing for workers' compensation claims
- 30-40% average savings on medical bills through forensic analysis
- Detection of unbundling, upcoding, and duplicate billing in injury claims
- Support for litigation and subrogation efforts with detailed documentation
- Independent medical bill validation for disputed workers' comp claims
- Compliance with state workers' comp fee schedules and regulations
- Auto liability and general liability medical claim cost containment
- Legal defensibility and expert witness support for challenged medical bills
For Re-insurers & Stop-Loss
- Reduced catastrophic claim exposure on medical reinsurance treaties
- Forensic analysis of high-dollar claims ($500K+) before attachment points
- Enhanced due diligence: Validate medical necessity for expensive treatments
- Improved loss ratios through overpayment recovery (avg 3-5% of large claims)
- Better underwriting with historical overpayment pattern data and analytics
- Lower claims exceeding specific deductibles ($100K-250K attachment points)
- Aggregate claim cost reduction for self-funded employer group portfolios
- Improved profitability and competitive pricing for employer clients
- 85%+ recovery rate on identified overpayments in catastrophic claims
- 4:1 to 6:1 ROI for high-dollar claim forensic review
- $200K-500K average recovery per catastrophic claim reviewed
Why Choose Avande for Cost Containment
Clinical Expertise, Not Just Data Analytics
Unlike vendors relying solely on automated algorithms, every finding is validated by board-certified physicians and certified coders. This ensures clinical accuracy, legal defensibility, and higher recovery rates on challenged overpayments.
- Board-certified physicians validate medical necessity
- Certified professional coders ensure coding accuracy
- Clinical documentation supports recovery efforts
Proven Forensic Methodology
25+ years developing proprietary forensic analytics specifically for healthcare claims. Our models identify sophisticated fraud schemes, billing patterns, and payment anomalies that simple edits and audits miss completely.
- Proprietary analytics trained on millions of claims
- Pattern recognition for complex fraud schemes
- Continuous model improvement from new findings
Full-Service Recovery & Prevention
Complete end-to-end service from identification through recovery and prevention. We handle provider outreach, negotiation, legal documentation, and process improvements—maximizing recovery rates while minimizing your administrative burden.
- 85%+ recovery rate on identified overpayments
- Professional provider relations and negotiation
- Preventive recommendations to stop future errors
Cost Containment Results
$3.1M Recovered Through COB and Fraud Detection
Coordination of benefits (COB) errors resulting in Medicare Advantage plan paying primary when secondary. Suspected pharmacy fraud schemes.
Comprehensive COB analysis cross-referencing multiple databases. Pharmacy claims pattern analysis identified fraud schemes including prescription splitting and doctor shopping.
- $3.1M total recovery (COB errors + pharmacy fraud)
- $2.2M in COB overpayments identified and recovered
- $900K pharmacy fraud detected and recovered
- 15 provider/pharmacy fraud schemes identified
- 89% recovery rate with legal support
Cost Containment FAQ
Ready to Recover Millions in Improper Payments?
See how forensic claims analysis can identify overpayments, recover funds, and prevent future payment errors
Schedule a consultation to learn how our physician-led review process delivers measurable ROI for your organization.
- $2-4M average annual recovery
- 85%+ recovery rate
- 3:1 to 5:1 ROI
- SOC 2 | HIPAA | HITRUST
