We show you how to recognize and avoid black holes.

Fraud, Waste, and Abuse

Where are you losing money? There are countless opportunities for fraudulent activities or inaccurate coding in the Medicaid, Medicare, and private insurance systems. We have decades of experience helping state agencies gather and analyze data to uncover vulnerabilities and establish robust oversight.

Data identifies potential problems.

Expertise weeds out the fraud and abuse.

Constellation Quality Health takes a data-driven approach to health care fraud and waste prevention. We analyze the integrity of data and medical record documentation to get a complete picture of areas of concern. With the support and expertise of our team, you can protect yourself from problematic providers, ensuring that health care dollars are being spent on intended services by quality providers. This, in turn, makes it possible for our partners to provide health care access and services to the beneficiaries who depend on them. We offer:

  • Payment integrity (medical, dental and pharmacy claims reviews) 

Using advanced analytics, we safeguard your payment system, assuring correct payments and detecting overpayments, invalidities, and fraud.

  • Investigations

Armed with a federal law enforcement background, we expose criminal and civil actions. We offer a fully outsourced Special Investigations Unit (SIU). 

  • Fraud compliance and training

Our customized fraud plans, policies, and procedures, and fraud awareness training will keep your organization CMScompliant. 

  • Fraud reporting management solution

We triage, manage, and investigate your fraud hotline reports to ensure effective, quick processing of complaints. 

  • Provider Audits

Our analysis of claims and supporting documents gives payers and SIUs valuable insights into provider compliance. 

  • Expert court testimony

We provide expert court testimony in support of health care fraud investigations.