Detecting Fraud Earlier, with Greater Accuracy

Overview

Where Prevention Becomes Possibility

Partnering with one of the nation’s largest Medicaid and Medicare Advantage providers, Commence built an AI-driven fraud detection workflow that combines real-time alerts with clinical oversight. We embedded real-time fraud alerts and clinical oversight directly into our medical outreach and retrieval platform—helping agencies and payers act sooner, investigate smarter, and recover faster.

Problem

Fraud Signals Were Getting Missed—or Misread

Payers had the data to identify fraud, but lacked a workflow to act on it in real time. Disparate systems led to delays, missed recoveries, and false positives that drained staff resources. The solution required more than just alerts—it needed integration, clinical validation, and insight that moved fast.

Solution

Turning Insight into Action

Working with government and commercial health plans, Commence connected a leading predictive analytics engine’s predictive analytics with our clinical review and retrieval workflows. Together, we created an end-to-end system that flags potential fraud cases early, routes them intelligently, and supports action with complete audit-ready documentation.

Impact

Precision Detection. Proactive Protection.

With Commence’s integrated platform, agencies saw a 45% increase in flagged fraud cases, with a 30% drop in false positives. Predictive alerts were routed directly to clinician-led medical review teams, enabling faster resolution and reducing investigative backlogs.

• 45% more flagged cases detected
• 30% fewer false positives
• Real-time alerts routed into case review workflows
• Structured case files generated for audits and appeals
• Oversight across Medicare, Medicaid, and commercial plans

This is healthcare fraud prevention in real time—with AI in healthcare that protects patients, programs, and public trust.