Access the podcast to hear healthcare experts discuss how Qlik Predict, Qlik Answers and Qlik Analytics optimize audit processes to identify attack trends and correct claim inaccuracies. Learn how healthcare teams enhance operational efficiency and performance tracking with actionable strategies that identify risks and validate billing policies.
[Anthony Jimenez]
Welcome back to Carahcast, the podcast from Carahsoft, the trusted government IT solutions provider. Subscribe to get the latest technology updates in the public sector. I'm Anthony Jimenez, your host from the Carahsoft production team.
On behalf of Qlik, we'd like to welcome you to today's podcast, focused around healthcare claims oversight. Dominic Berger, Program Management at Ashland Management Group. Tim Gaffert, Senior Data and Analytics Consultant at Ashland Management Group.
Andrew Churchill, VP of Public Sector at Qlik. Patricia Kelly, Clinical Consultant at Case and Life Care Management Consulting, LLC. And Anita McCreevy, Senior Clinical Consultant at Health and Management Consulting, LLC.
We'll discuss how Qlik's AI-powered tools can transform your healthcare organization.
[Dominic Berger]
My name is Dominic Berger, Project Manager and Director and Solutions Lead at Ashland Management Group, and I have the privilege of serving as today's moderator. First, let me start by extending a heartfelt thank you to all of you, our attendees, for joining us today. We recognize the critical and challenging work that you do every day, and we're excited to share some cutting-edge AI and data analytics solutions that can support your mission.
Joining me today are four distinguished speakers. My colleague, Tim Gaffert, who's a Senior Data Analyst and Dashboard Developer at Ashland Management Group, who's going to walk us through one of our AI-powered solutions today. Tim brings years of experience in applying advanced analytics to solve complex operational challenges and improve decision-making.
Also joining us today, we have the privilege of Andrew Churchill, who is the Vice President of Public Sector at Qlik. Andrew leads all sales and go-to-market efforts for the federal, SLED, and higher education markets for Qlik. And then later on in today's session, we'll have a fireside chat with two SMEs within the space.
Anita McCreevy, who brings more than 40 years of experience in the healthcare industry. Her areas of expertise includes Medicare, Medicaid compliance, quality management and improvement, preventative programs, and clinical practices. Also joining the fireside chat will be Patricia Kelly, or Patty.
And Patty has worked in healthcare also for over 40 years and expertise in both provider, insurer, in the fields of care management, utilization management, claim review, quality improvement, with a focus of both commercial insurances, as well as CMS, Medicare, and Medicaid. I'd also like to thank and acknowledge our collaboration partner, Carasol, for organizing and hosting today's webinar. Today, we'll showcase how Qlik's powerful analytics ecosystem can help auditors or healthcare claims managers proactively investigate, adjudicate, and mitigate fraudulent or incorrect healthcare claims.
Today, we'll explore how to quickly identify claims in states and providers with financial exposure for claim inaccuracies, investigate flag claims, and instantly validate billing policies using Qlik's AI tool, Qlik Answers, powered by official documentation resources. Also, we'll showcase how Qlik's capabilities to identify and forecast trends, prevent behavior proactively, and forecast future risks. And then lastly, we'll enable strategic decision making and significant cost avoidance with the advent of this tool.
I'd like to first take a moment to introduce the members of today's webinar, Ashland Management Group, as well as Qlik, and highlight how together we bring innovative solutions to support mission-critical needs of our customers. Let's start with Ashland Management Group. So for nearly 30 years, Ashland has been building solutions and providing services to federal, state, and local agencies, helping them fulfill their missions and positively impact the communities they serve.
As an authorized Qlik public sector partner, Ashland specializes in developing custom Qlik solutions tailored to our customers' unique needs. We also go beyond just implementing technologies by providing dedicated success engineers who work closely with clients to maximize the impact of their Qlik solution investments. We're committed to deliver value and ensuring the tools we implement drive real results for your operations.
Now briefly, before I pass it to Andrew to speak more about Qlik, Qlik is an industry-leading software provider, recently recognized in the 2025 Gartner Measure Quadrant for analytics and business intelligence platforms. Qlik has been helping organizations across the globe harness the power of their data to solve problems and achieve new goals and address critical needs. Qlik has cutting-edge solutions in data integration, analytics, and AI.
Together, Qlik and Ashland form a powerful team. Our partnership is uniquely positioned to tackle specific needs of our customers. For example, in today's session, transforming claims management, enhancing audit efficiency, and reducing financial risk.
We're excited to show you how our combined expertise and solutions can make a difference in your work. Now I'll pass it to Qlik's Vice President, Andrew Churchill, to tell you more about Qlik and the great work they're doing to support customers' missions. Andrew?
Fantastic.
[Andrew Churchill]
Thank you, Dominic. And I'm really grateful to be here, thankful for this partnership. You may or may not be familiar with Qlik.
We've been a leader in multiple magic quadrants, a leader in data analytics, data quality, and data integration for the longest period of time in most of those competitive groups. We support the largest organizations in the world and in the public sector, support over 150 different federal agencies, over 200 different state, local, municipal organizations, as well as nearly 200 higher education institutions. For us, we're in a very highly regulated market, whether it be healthcare or federal.
We've made huge investments in bringing our technology in the right platforms and getting the certifications that are required to support these unique use cases. Today, we offer Qlik Cloud Government. It's hosted in AWS GovCloud West.
It's our FedRAMP Moderate solution, soon to be FedRAMP High. It's also got a HIPAA certification, as well as supports the USDISA DoD and IL4. Qlik began as an analytics customer, but through multiple acquisitions and organic R&D development, has built what I would say is the broadest, most complete data platform for data integration and data analytics in the market today.
We support our customers by helping them capture data from transactional systems, from streaming and from document stores, and delivering that in either real time or in batch mode, getting it ready with the types of transformations that you need to be able to take an HL7 or an EDI or other XML formats from large volume systems like your ERPs and billing systems, and then run that through rigorous processes to both get that data homogenized so that it could be ready for consumption on the analytics and AI end, but also to validate its readiness for use.
Data quality is a huge issue when we start talking about fraud, waste and abuse and oversight. Sometimes because the data is intentionally has issues or unintentionally has issues, but having solid data that's as complete and consistent as possible is really important in making sure that your analysts are able to do the task that you're asking them to do. On the consumption side, on the analytics side, what we'll focus on today, Qlik is really uniquely engineered for this type of problem.
Our engine, what we call our associative engine, really allows you to look at all of your data rather than narrowing an aperture as you go through and make a number of SQL queries. I spent most of my 30-year career supporting Medicare and Medicaid, in fact, and you know that when you start looking across beneficiaries and providers and all of the transactions that exist, I'm really excited for you to see what the potential is when you start looking at this. Beyond dashboards, though, that's really where Qlik is headed.
We're investing heavily in AI that makes the job easier across this whole platform in this stream, as well as AI tools that will make it easier for you to discover the things that you need to be looking at. And that's not just native. We're a very open architecture, looking for ways to be able to integrate with other LLMs, with other AI tools, to bring really the best possible capability to market.
And finally, the big focus that we all have right now is, you know, how do we move beyond just being able to identify that something's interesting and into taking action on that, no matter what that action might be? Whether that's an agentic type of approach, very popular phrase these days, or just a workflow that kicks off a case management ticket being opened. These are the capabilities that Qlik's building in so that you can automate processes and really get the most out of your data, take advantage of the analysts that you have, and get their eyeballs on the right things.
We're doing this today across the public sector market. So today, we support CMS in a variety of different programs, largely from a data integration perspective. At HIOS and with the fraud prevention system underneath the insurance over underneath the Center for Program Integrity, we are taking volumes of data from across many, many different systems and getting it ready for analysis.
This is absolutely essential, and that with the number of data sources growing, you really need automated low code, no code types of technologies that don't require that you hire more and more staff to keep up with the data volumes. Pipelines should be easy, they should deliver real-time data that's trusted and ready for use. Out in the state and local space, we've got customers like CalSOS, which use Qlik for eligibility determination across the largest set of health and human services programs in the U.S., and in places like Florida Department of Health that are really looking broadly across all of their health and human services programs, looking for fraud, waste, and abuse, but also trying to improve access to their citizens.
We're super proud to be able to provide a role and really excited about the opportunity that lies ahead as AI helps drive us forward and us working with partners like Ashland. Back to you, Dhamak.
[Dominic Berger]
Thank you so much, Andrew. And like I said, we're excited and always excited with our partnership with Qlik. And then, you know, thank you for highlighting such a great value in the work that Qlik is currently implementing across federal as well as the state and local government.
And we both understand the unique challenges of claim management, making sense of vast amounts of critical data. And so, you know, before I pass it to my colleague, Tim, today, I'm going to give a kind of preview of the Qlik Power Solution, the medical claims dashboard that will show and really highlight how to harness all of your claims data into one centralized location, providing insights that not only help you understand what's happening now, but most importantly, forecast what's likely to happen next to plan and make adjustments. And so, here's kind of a highlight example of how, you know, the process of bringing in all that information into one centralized place so that we can build these robust tools within Qlik to help kind of harness your data. And so, now I'm excited to introduce our medical claims dashboard, and I'll pass it to my colleague, Tim, to walk you through it.
[Tim Gafvert]
Tim? Thanks so much, Dominic. Yep.
So, today I'll be walking through the CMS medical claims dashboard, a Qlik powered solution designed for program integrity teams to identify and recover improper payments. So, the data you see is simulated, but it mirrors the structure and complexity of real CMS claims feeds. Each flag claim is generated from both rules-based logic, like modifier misuse or duplicate billing, as well as statistical modeling, which detects outliers in billing behavior.
Together, they create a realistic audit environment to show how this tool performs in production. So, I'll be stepping into the role of a program integrity analyst whose goal is to pinpoint high-risk claims and validate them against policy, then initiate recovery before quarter end. We'll start with the overview sheet, seen here, to assess whether the largest financial exposures are where they are, then drill down into individual claims for verification.
So, this overview sheet gives me a high-level picture of our current audit landscape. At the top, I can immediately see two metrics that define a scope, total potential clawback of roughly 34.7 million and close to 9,000 flagged claims awaiting review. These numbers represent funds that could potentially be recouped once validation is complete.
On the left, the flag claims by type chart shows where most of these issues are coming from. Upcoding alone accounts for nearly a quarter of all flags, followed by unbundling and modifier misuse. This helps me to understand not just the volume, but the nature of the errors driving the impact metric.
The map in the center highlights potential clawback by state. As I scan across the country, I see states with darker shades indicating a higher concentration of recoverable dollars. That tells me that those areas are worth closer review.
On the right, the flag claims by month chart helps me spot timing patterns. There's a clear rise in December, which often coincides with end-of-year billing surges, which is a common time for audit anomalies. Putting this all together, my first takeaway is that Illinois shows a significant financial opportunity.
That gives me a logical starting point for a deeper audit. Now, to investigate further, I'll drill into Illinois. Now that it's drilled into here, I can immediately notice the different providers that are categorized under this state.
I can notice that Westwood Psychiatric Center has an unusually high potential clawback value, large enough to warrant a focused review. With that, I'll move to the adjudication sheet to look directly at the flag claims for this provider and verify whether the findings hold up against CMS policy. Now on the adjudication sheet, the focus shifts from statewide trends to individual claim level detail.
This is where an auditor would begin verifying the validity of each flagged record. On the left here, we have a breakdown of frequent issues by provider, showing which facilities are responsible for the greatest number of flag claims and the issue types driving those flags. You can see Westwood again near the top with a mix of upcoding, unbundling, and modifier misuse contributing to the overall total.
On the right, we have a detailed claims list. Each row represents a single claim pulled from the adjudication feed, complete with claim ID, procedure code, issue type provider, and diagnosis code. As a program integrity analyst, I have the opportunity to select the individual providers.
For example, if I Qlik onto Westwood Psychiatric Center, the table will narrow down to claims that fall into that category. Now this is where I'll select a record to begin manual review. At the top, I see a claim flagged for modifier misuse, and I can immediately see the related CPT code as well as the diagnosis and description of the issue.
The details column provides context on why it was flagged. In this case, it was due to a billing modifier that's not supported by the documented service. So at this point in the process, the analyst's task is to determine whether the claim was appropriately billed or if a recovery is justified.
To make that verification faster and more defensible, we can now go to our Qlik Answers section. Qlik Answers acts as an AI-powered audit assistant built directly on top of Qlik. It allows reviewers to ask natural language questions about policies, billing rules, or documentation and get near-instant citation-backed responses from up-to-date sources.
So returning to our earlier example of Westwood Psychiatric Center, I had a claim flagged for modifier misuse. But rather than searching through hundreds of pages of CMS policy, I can simply ask, is modifier 25 appropriate without documentation of a separately managed service? Qlik Answers immediately references the official CMS documentation and confirms that the modifier is not valid in this scenario.
It also provides the exact policy citation as well as a direct link to the source, giving the reviewer everything they need to document the finding. This interaction is not scripted. It's pulling directly from unstructured data in the background, including billing manuals, audit criteria, and policy updates, all indexed for quick retrieval.
By embedding Qlik Answers directly into the dashboard, we've removed a friction point in claims review, the need to leave the analytics environment to search for supporting evidence. Reviewers stay in context, validate faster, and make defensible audit decisions supported by verifiable documentation. Once a claim is confirmed as invalid, the finding is logged, and the clawback workflow can begin.
But beyond one-off verification, the same capability can surface broader trends. For example, identifying providers who repeatedly misuse the same modifier or bill procedures outside of a standard policy. So, moving to the claim trend analysis sheet, we can ask the next question.
Is this a one-time error or part of a recurring pattern? And this is where the claim trend analysis sheet, powered by QlikPredict, comes in. This uses historical claims data and machine learning models to forecast where overcharges are most likely to occur in the next month.
At the top, we can see the predicted overcharge amount, about 2.36 million, and the number of high-risk providers, currently 28. These metrics show not just what has happened, but what is expected next. On the left, the Providers at High Risk of Increased Overcharging chart ranks facilities projected to show rising improper billing.
Once again, Westwood Psychiatric Center appears at the top, reinforcing that this isn't just an isolated issue, but instead an ongoing trend in their billing behavior. On the right, the Estimated Overcharges by Issue Type Tree Map breaks down those predictions across common categories. We can see falsified or inflated services, modifier misuse, and upcoding leading the list, together accounting for the majority of projected overcharges.
From an analyst's perspective, this information shifts the workflow from reactive to proactive. Instead of waiting for claims to be paid and later clawed back, teams can use these risk forecasts to target reviews, prepayment edits, or provider outreach before funds go out the door. So now filtering back on Westwood Psychiatric Center, we can see here that the model predicts nearly $100,000 in potential overcharges next month tied to modifier misuse alone, a direct continuation of what we've seen in prior months.
That gives leadership a clear, data-driven justification to prioritize this provider for education or corrective action. Taken together, the predictive layer closes the loop on the entire dashboard from identifying existing improper payments, verifying them against policy, and now forecasting where the next ones are most likely to occur. In short, QlikPredict helps program integrity teams get ahead of the problem using data not just to recover more money, but to prevent those future losses.
Thank you very much, and I'll pass it back.
[Dominic Berger]
Thanks, Tim, for walking us through. So let's just give a recap of some of the innovative features that Tim walked through today and how the solution is really designed to help you unlock full potential of your data, transform the claims management, enhance audit efficiencies, and most importantly, reduce the financial risk to the healthcare industry. And so first, Tim talked about the way that the tool can help identify flagged claims, highlighting Qlik's analytics capabilities to identify the volume and geographic distribution of these flagged claims within the visualizations with both an executive-level view as well as a more detailed visualization to present findings to the auditor level.
The tool can be customized for both. Also, next he explored how Qlik answers the generative AI system that streamlines all of that medical claims documentation in review and help quickly analyze and summarize complex information with speed and accuracy with the tool. And lastly, what's the tool?
This is the biggest thing that's happening. What's happening now, forecasting what's happening in the future, but most importantly, help leverage Qlik Predict, the no-code machine learning feature, to enable proactive decision-makings through that forecast risk assessment, providing actionable insights to improve planning and mitigation strategies for future claims. And I hope that the demonstration itself kind of showed the breadth of Ashlyn and Qlik's capabilities for harnessing that claims data from the tracking perspective, predictive analysis, to advanced AI-assisted research, really focusing on how these features show today but also can be customized for your use case to really help transform your organization's claims management and enhance that audit process. But the biggest thing I wanted to highlight is a purpose of the tool. So it's not just about having the punitive piece, right, being able to identify additional maybe incorrectly filed claims or maybe even fraudulent claims, and not only as well to identify the funds for callback, but really the tool was designed to help better understand where the challenges are within that claim system to identify potential opportunities to perhaps maybe provide training or resources to the community who's utilizing or submitting those claims to help support them and to reduce some of those errors or even those false claims.
So really, the overall purpose is really to help improve the claim systems in the process for the population. And so now I'll bring in our SME panelists for a fireside chat to really discuss maybe some more detailed claims use cases and how a tool like this Medical Claims Dashboard can provide value. So I'll bring in, like I said, Anita and as well as Patty, who both bring over four years of experience within this industry in this claims management information.
So good afternoon, Anita and Patty. First, I just wanted to start, just get your general feedback or your thoughts on the tool today and kind of the value you could potentially bring overall to the claims management ecosystem.
[Anita McCreavy]
And so Patty and I have spoken before about how long we've been in the industry. And I remember one of the first consulting projects we had was for a Medicaid state program to identify audit issues and overspending. And it was all manual.
I mean, we literally had charts piled up everywhere. It was crazy. So having this day and age when you can do things, not just historically, like I just mentioned with the PACE program, but prospectively, I think is the key because everybody's moving to that now so that you can try to avert issues.
Can we identify where education is needed? And where some changes might need to occur with process versus technology? I know one of my first barriers even in reporting to the government and HEDIS measures was the clearinghouses because they would collect a lot of the claims directly from a lot of the MCOs.
And then on the back end would only kick out maybe five diagnosis codes when you need it all. So little things like that to identify the barriers with even data flow is key for me as well. Patty?
[Patricia Kelly]
I think also the tool itself will allow for the identification from a clinical perspective, trends in care, and then seeing how providers are treating specific diagnoses. So as an insurer or a vendor or provider, you can identify where our benefits lie, do they need to be tweaked to support new trends in management of members? So I think it's a really important thing to be able to identify those trends through this type of tool.
So.
[Dominic Berger]
Thanks, Patty, Anita, for that. And like I said, it is helpful, you know, understanding, you know, which this tool was out previously, but, you know, it's out now to really help support and move the process forward with technology. So now let's kind of deep dive maybe into some particular claims use cases and kind of, you know, identify where, you know, a tool like this can provide value to the community.
So we can start with first, you know, in the non-emergency transportation claims process. So let's kind of talk about that use case within the claims management system and, you know, maybe talk through, brainstorm some ideas of how a tool like this medical claims dashboard could support. So we can start with you, Patty.
[Anita McCreavy]
I actually started with a program with logistic care in Pennsylvania, and they were managing the account, I guess, for the Medicaid program. And I took careful records of the utilization because it was a BC project we were working on for the families in the Medicaid program. And it was very manual.
And I just thought there's going to be so much abuse of this. So, you know, and we've seen actually, Patty and I, through our clinical practices and work, a lot of abuse of the non-emergent transportation. And then the reverse barriers to what Tim brought up earlier of where you might have a handicapped adult where the family member or caregiver needs to take them with them, and they weren't allowing that.
So it had to do prior approval. So there's a lot of, you know, things I think that non-emergent can support. Patty?
[Patricia Kelly]
I agree with Anita. I think with the non-emergency type of transports, there is a lot of FW, fraud, waste abuse there. We have a good friend of ours who works in that arena, and they're constantly identifying the types of transports that are occurring, and you've got to make sure they're falling within the guidelines.
And also based off of that, a lot of the special needs plans that are coming into the arena, and they're all over the place and in every state now, they're using non-emergency transport for different items because it's part of the benefit package. So this, again, allows for the identification of tracking the trends, what's going on, and if it's being used appropriately or inappropriately, and what should we do about that. So it starts to beg the questions that need to be answered through the use or misuse of service such as that.
[Dominic Berger]
Yeah. So, you know, sounds like to me, you know, the biggest connection, you know, how it's for one, you know, bringing in, like you said, the different policies and procedures for each one of those types of claims, I'm guessing they're highly detailed. So, you know, the tool like Quick Answers can bring in all that information to help folks who are monitoring that, you know, sift through and identify the accurate information for identifying those claims, whether it's accurate or not.
So that could be a good use case as well. So the next kind of use case potentially we could talk about is with, you know, the home and community-based services claims, you know, thoughts around, you know, that within, you know, the fraud, waste, and abuse within that, and then how, like I said, the tool like this can provide value.
[Anita McCreavy]
Yeah, this has definitely been hot on the discussion, I think, recently because there's a lot of, kind of like you just spoke to about social determinants of health. So community-based services is being used and a lot of the vendors or providers like Bravo or some of those others, they tend to not utilize the systems to monitor what's actually going on in the home. Some of them have technology where you have to log in on an iPad and identify, you know, what you're doing for that day.
But to be able to analyze it, like Tim was talking about, on a global scale and identify where there's some overspending or where folks aren't really doing what they're supposed to be doing and just logging in.
[Patricia Kelly]
And I was thinking about it as we talk about it, and I think it also helps to benefit the member side, because what happens too is, and I know that I've done it and I know family members, they look at the bill that they get from, you know, this EOB, you know, Exploitation of Benefits, and then they're sort of going through and saying, I don't remember getting this done, I don't remember them showing up here or doing that. So again, it allows, this type of system allows to track those trends for the over or under use of services that are either not being rendered or not being rendered appropriately.
[Dominic Berger]
Yeah, that's great. And like I said, it sounds to me, you know, just in your discussions, one of the other things, you know, could be a benefit is on the back end, as we talked about early, all of these different kind of data inputs, right? You know, it can be coming from different sources, but, you know, what are the things that the system can do and what the support is, is bring all that information into one place so that it can be analyzed and, you know, provide predictive analytics and decision makings to help, help the process going forward.
[Anita McCreavy]
You know, underutilized too, because I think that's where we found in the beginning, when a lot of these, you know, programs started to come out with transportation and community based, a lot of people didn't know what they actually did or how to use them. And so I think to identify, you know, back to what Tim was saying about identifying what barriers are access to care is huge with special needs programs, especially because they're trying to keep people in the right settings and a lot of them want to stay home.
[Dominic Berger]
That's great. And that's good, you know, how you brought up that underutilization, right? That goes back to the tool helping, you know, the improvement of the whole system, right?
So like I said, it may be, you know, not only that it's being unutilized, that can tie to maybe providing more resources or training to the community so that folks are aware of, you know, what's available and then how to correctly file and process those information. The next claims use case I want to touch on is the physician claims. And we can start with you, Anita.
[Anita McCreavy]
Well, actually, I think I'll start with Patty, because she has a lot of history with the physician claims.
[Patricia Kelly]
I think, well, because I have a history of doing claims review and claims analysis, many times you're seeing, and this is where we talked about your tool that your system being able to use as a tool to identify either inappropriate or misuse of, you know, modifiers and being able to help educate the provider. Because as our system moves so quickly within the healthcare arena, things are changing all the time. And because a lot of things you'll always hear, we always did it that way, we always use that modifier.
But with the changes that are occurring so quickly, it allows that opportunity to track, trend and re-educate the providers so they can, you know, bill appropriately. Because we don't want to assume that everybody's doing it because they want to create fraud, waste, abuse. We want to assume that they're doing everything for good intention until shown not.
So I think that that's part of this process that, you know, unbundling codes so you can bill individual items. Well, you know, maybe it's the person who's doing the claim and billing that doesn't understand. You can't unbundle that or that's another code that you should use.
And so again, and also looking at targeting the diagnoses that support what is being billed through the CPT codes and the HCPCS codes. So, I mean, these are things you want to be able to look at and the system would allow to do. In my mind's eye, that's what the system would allow to do to make those adjustments.
And again, looking at clinical practices and trends, you know, to see, do we need to adjust our benefit packages because there's something going on in cancer? This arena for treatment protocols is much different than what we were used to seeing. So what is going on?
So it gives that opportunity too. So it's a usable system tool to identify things that are going on within the physician practices.
[Dominic Berger]
That's great. And as you spoke, one of the things that, you know, staying ahead of the changes, right? So we're constantly changing codes or policies.
One of the things Tim touched on, but I'll bring it up with the quick answers tool to access to all of those policies for research. You know, on the backend, those knowledge bases can be directly connected to organizations kind of living document so that, you know, the latest version is always, you know, available to be able to get that information to support those users of the tool. So that, you know, one of the things that within that active knowledge base, you know, allows that everybody's reading from the most accurate, you know, kind of sheet of music, so to say, to be able to provide information and support their day-to-day operations.
Next, we can touch on, you know, within the, you know, durable medical equipment claims space and kind of thoughts around that.
[Anita McCreavy]
Oh, yeah, that's another big one, because nowadays people are getting things in the mail that they shouldn't be getting. And they said, I never ordered it. Kind of what Patty spoke to earlier about, you know, fraud or abuse coming in.
And that actually happened a lot with my mom. She was a three-timer for strokes. So I was constantly averting as a medical lead in her care to say, you know, this is not hers.
We got to send it back and make sure it's not on what Patty described earlier about the EOB. So it's having something and a tool to be able to identify even on a larger scale for the state programs and try to find that abuse and put a process in place to avoid it. We used to have the packs for the kids with the monitors.
And I always teased they were going to go to college with those monitors on because they never sent them back.
[Patricia Kelly]
Yeah, and a lot of times these DME items, they capitate for their costs. And instead of the provider or the vendor, you know, capping it and buying it and purchasing it for the member who's still using it, they continue to bill inappropriately for that monthly charge. So these are things that the system, again, would allow to track and trend and by detailing it down to the actual item.
So especially those things that are expensive, because we know there's patients that go home on certain machinery and they don't need it after a certain point because their recovery is good. And maybe it's still sitting there. The hospital bed is still sitting there that's never gotten picked up.
So, but the charges are coming through to the health insurance company. So these are things to track, to trend and look for that FWA throughout the system as well.
[Dominic Berger]
I think, you know, kind of the next two we can maybe group together within, you know, pharmacy and as well as laboratory testing claims, you know, kind of to be able to support those use cases as well within the space. We'll start with you, Anita.
[Anita McCreavy]
Oh, sure. So pharmacy kind of tied with the DMA, like they're automatically sending a lot of medications to the house if you're signing up for scripts or some of these 90 day programs. And, you know, your physician may have changed your prescription, but you still get stuff in the mail.
So, you know, and once they process medication, you can't send it back. It's one of the legal issues around that. Same thing with lab testing.
It's funny because I had an allergic reaction to go to the ER about a month ago and they drew labs and I'm like, no, you didn't process them. So again, back to the EOB and checking things out.
[Dominic Berger]
Sure. I think we have time for the last use case. So the community mental health claims arena, which I know, you know, it's trending in a lot of spaces as well.
So some kind of thoughts around that area within the use case and the claims management.
[Anita McCreavy]
It's funny, Patty, because we're just kind of talking about that in reference to facilities versus community based places where people go and then some are actually out in the street. So they visit them, visit the homeless. And so to be able to track and trend that, especially since it's such a big area of focus right now in all the states and around the mental health focuses that we have, it's huge.
[Dominic Berger]
All right. Well, like I said, I'd like to thank you, Patty and Anita, for your kind of thoughts and expertise in this space, but really tying to the benefits of having technology to support to not only, like I said, identify what's happening, you know, those fraud cases, but really try to improve the whole ecosystem because there's so many areas as I listen to be able to, you know, mitigate financial risk for all of these different claims industries and, you know, just be able to track and forecast, you know, things would, you know, be a huge help is my thoughts in this industry. I'd like to thank you again for you both for joining us today.
[Anita McCreavy]
You're welcome. Thank you. Thank you.
[Dominic Berger]
And I'd also like to thank all of you for joining us today and exploring how this quick AI-powered tools, you know, turn claims data into actual insights and how, you know, these solutions really go behind beyond just static dashboards, but really offering proactive, predictive, and automated intelligence to, you know, transform claims management, enhance audit efficiency in the, you know, overall reduce that financial risk.
[Anthony Jimenez]
Thanks for listening. And thank you to our guests, Dominic Berger, Tim Gafford, Andrew Churchill, Patricia Kelly, and Anita McCreevy. Don't forget to like comment and subscribe to Carahcast and be sure to listen to our other discussions.
If you'd like more information on how Qlik can assist your organization, please visit www.Carahsoft.com or email us at Qlikmarketing@Carahsoft.com. Thanks again for listening and have a great day.