CGI in payment integrity: Delivering innovation, value and results

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Pre-submission, prepay, post-pay

CGI’s holistic solution provides
automation for the full medical claim
lifecycle, allowing the client to decide
when to review the claim.
 

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Strategic partnership

CGI partners with payers and providers on
key strategic and tactical elements to
continuously improve the claim lifecycle
with the goal of paying the claim accurately
the first time.
 

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Human-centered AI

CGI focuses on the responsible use of AI by
integrating advanced technology with human-in-
the-loop validation to automate processes while
increasing accuracy, efficiency, and scalability.
 

30 years of payment integrity expertise

Our team of specialized industry experts has more than 30 years of experience analyzing and auditing government health plans, managed care and private insurance medical data. Our team includes clinicians, data scientists, health information management professionals, payment integrity operations specialists, claims operations specialists, and IT experts with business experience from relevant healthcare payer industries.

Business and strategy
  • Over 25 years of experience
  • Payment system conversions to prospective payment systems (weights, rates, policies)
  • Medicare payment system modeling
  • Payment integrity operations analysis & management
  • HiTrust program management
  • BlueCard operations and BCBSA compliance
Clinical
  • Physician advisors
  • RNs with average 10+ years acute care ICU experience
  • Coders with average 10+ years acute care coding experience
  • Specialty experience in:
    • Charge and iBill review
    • Behavioral health, LTAC
    • Pharmacy, Data Analytics, Business Intelligence
    • Home Health, DME
    • Medical Necessity
Support
  • U.S. based
  • Onshore support based in Troy, Alabama
Data analytics
  • Over 25 years of experience
  • General and health care specific analytics
  • Building machine learning models
Technical
  • Over 15 years of data architecture and SaaS/PaaS experience
  • Software Security Awareness training for Coding and Testing by Cigital
  • Data Architect (MIT graduate)
  • Designations:
    • Health Insurance Association of America
    • Managed Healthcare Professional
    • Health Insurance Associate

 

Learn more about our innovative payment integrity solutions

CGI ProperPay

If you need a proven way to predict, identify, manage and recover improper payments, driven by advanced analytics, discover discover CGI ProperPay. Since 1990, our solution has helped payers/insurers improve payment integrity and recover well over $3 billion in improper payments.

 

Recovery audit solutions

As a leader of innovative solutions in the healthcare payer/insurer industry, we help clients reduce and recover lost revenue. Our comprehensive healthcare payment integrity solution maximizes recoveries while developing new policies to reduce error rates and unnecessary spending.

Reimbursement solutions

Well-developed reimbursement methods control medical costs, improve payment predictability and provide a method to compare the cost effectiveness of providers. From small to large payers, put our expertise to work for you.

CGI's payment integrity performance by the numbers

30+
years supporting
payment integrity 
360ₒ
payment integrity offering driven
by solutions and services 
500%
increase in audit efficiency
through integration of AI 
$3+ billion
in improper medical claims payments
have been recovered for government
and commercial payers 
96%
appeal uphold rate

Ready to learn more about our payment integrity services?

Connect with out team to learn how we support the payer industry, delivering the best complex-audit-review overturn rates in the market through our suite of innovative solutions and services.

Client partnership experience

With more than 30 years of experience in government and commercial health plans, we know what clients value. Let us help your organization address fraud, waste and abuse.

Over our long-term relationship, CGI has been an incredibly reliable vendor that continuously drives outstanding results while consistently looking for areas of improvement. Our success with combating billing and coding errors and abuse continues to be accelerated by our partnership with CGI.

Kurt Spear, Vice President, Financial Investigation & Provider Review, Highmark Health

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