Protect your organization from fraud, waste and abuse
Government agencies and commercial enterprises can promote the integrity of their programs by identifying and addressing fraud, waste and abuse.
How organizations can benefit from fraud, waste and abuse protection
SafeGuard Services (SGS), a subsidiary of Enterprise Services, performs data analysis, investigations, and medical review to detect, prevent, deter, reduce, and make referrals to recover fraud, waste, and abuse (FWA).
Since 1999, SGS has prevented more than $9.3 billion in inappropriate payments, consisting of over $5.8 billion in proactively Prevented Dollars and $3.5 billion in Recovered Dollars.
Our experience with fraud and abuse analytics has resulted in the referral of hundreds of cases to law enforcement and resulted in successful criminal and civil prosecution and civil monetary penalties.
Benefits of the program safeguard services offered by SGS include:
- Increased profitability through recovery of past overpayments and through mitigation of future fraud, waste, and abuse loss
- Ability to conduct predictive analysis to support investigations
- Reduced risk of predatory attacks through strengthened policies and enhanced use of automated prepayment protection
- Reduced risk of adverse publicity and increased potential for positive publicity regarding proactive approach to address fraud, waste and abuse
- Collaboration with stakeholders on approach and preventive measures
Effective and Secure Processes with High-Quality Outcomes
When you work with SGS, you work with a team that is:
- Effective - SGS effectiveness has allowed the organization to grow to become one of the largest contractors addressing fraud, waste and abuse for CMS.
- Secure - The data being analyzed is highly protected. The SGS Security program is based on the National Institutes of Standards and Technology (NIST) 800-53 security controls to allow SGS to conform to requirements for federal systems, auditable under the Federal Information Security Management Act (FISMA).
A variety of services to fit your needs
Services offered by the SGS team include:
- Data Analysis - SGS data analysts and statisticians apply a wide range of detection capabilities, including predictive modeling and complex data mining. Our data analysts apply the business intelligence tool best suited to the need, including various SAS statistical analysis tools, more traditional ad-hoc query tools, geographic mapping, and other tools.
- Investigation - SGS investigators substantiate the allegations by analyzing associated records. Desk-level investigations include analyzing information about a subject such as enrollment, claims, and other background data. Field work may include physical address verification and interviews with beneficiaries, participating physicians and their staff, and others.
- Overpayment Calculation and Recovery - To identify occurrences of error, including overpayment, SGS analyzes a statistically representative sample of payments, and then projects findings to the universe as appropriate, resulting in a recommended recovery.
- Medical Review - Medical necessity review is performed by a highly skilled SGS clinician who considers rules and policies as well as standard medical practices in evaluating the service performed and claim billed. This type of review is a thorough examination of a provider’s billing practice and may result in education or an overpayment determination. Fraud-level review, also performed by skilled clinicians, is less focused on necessity with the objective of determining if the services were payable as billed or occurrences of potential fraud, waste or abuse. In these situations, it may be determined that services were not rendered or the claim may be denied for technical reasons.
- Support for Civil and Criminal Prosecution - SGS applies extensive experience working with law enforcement to effectively prepare cases for civil and criminal prosecution, including having SGS analysts and investigators provide testimony, when appropriate.
- Prevention - SGS applies experience to promote loss prevention by recommending enhancements to payment systems, to proactively pay claims correctly, and minimize future overpayments.
SGS’ primary client is the Centers for Medicare & Medicaid Services (CMS), the federal entity responsible for protecting the Medicare and Medicaid healthcare programs from fraud, waste, and abuse.
- Large Scale - Medicare is the largest healthcare program in the nation and SGS is one of CPI’s largest contractors, delivering Medicare FWA safeguard services.
- Volumes - SGS protects approximately 437 million new annual claims, 18 million beneficiaries, 900,000 providers, and 21 states and territories.
- All Claim Types - SGS delivers integrity services for all provider types, including medical institutions, professionals, suppliers, and drug plans.
For more information
To learn more about how your organization can benefit from the fraud, waste and abuse services provided by SGS, contact:
Chief Operating Officer