Skip to content
BlogsHealthcare Fraud, Waste, and Abuse: Examples, Risks & Prevention
Understand healthcare fraud, waste, and abuse, its financial and operational impact, real-world cases, and how AI is changing FWA prevention.
Stakeholders We Work WithA Seat at the Table for
A Seat at the Table for
Every Stakeholder We Serve
Health plans, providers, TPAs, and government programs all run different operations. Here's how HealthOS meets each one exactly where it already is — on one shared data core, with AI PASS underneath every workspace.
HITRUSTSOC 2 Type IINCQACMS
Health PlansMedicare, Medicaid, Commercial, and Specialty PlansProviders & Health SystemsHospitals, Physician Groups, and Integrated Delivery NetworksGovernment & Public HealthFederal, State, and Local Agencies and Public ProgramsTPAs & Risk Bearing ProvidersThird-Party Administrators, ACOs, and Captives
Live signal96%Clean claim rate
Health Plans
Medicare, Medicaid, Commercial, & Specialty Plans
Running multiple lines of business usually means running multiple systems, each with its own version of the truth. HealthOS Plan handles RAF accuracy and Star Ratings while CAPS keeps claims and eligibility moving, all on the same record.
- RAF & HCC Pressure — Risk adjustment accuracy shows up directly in revenue, and most systems catch gaps too late to act.
- Star Ratings Visibility — Performance is often a report read after the measurement year closes, not a live view.
- Administrative Cost — Cost scales with claim volume instead of shrinking as operations mature.
HealthOS Plan96%Clean claim rate
87.3%HCC capture rate
20–40%Lower administrative cost
1Record across every line of business
Providers & Health Systems
Hospitals, Physician Groups, & Integrated Delivery Networks
Providers want the visibility a health plan has without becoming a health plan's IT department. HealthOS Provider keeps directory, credentialing, and contracting current automatically, not stale.
- Stale Directory Data — Credentialing and directory information is often out of date the moment it’s exported.
- Referral Leakage — Outdated network information sends referrals out of network by accident.
- Late Quality Data — Metrics arrive too late to influence contract negotiations.
HealthOS Provider88.4Avg. quality score
3,455Fully credentialed clinicians
30–50%Faster credentialing
LiveDirectory, not a quarterly extract
Government & Public Health
Federal, State & Local Agencies, & Public Programs
Public programs carry a compliance and reporting burden most commercial software wasn't built for. HealthOS was, with every automated decision logged in a complete, audit-ready trail.
- Compliance Burden — Audit and reporting requirements exceed what most platforms log by default.
- Dispute Timelines — Resolution windows are difficult to meet with manual processes.
- Multi-Program Reporting — Obligations span multiple state and federal programs at once.
HealthOS Sentinel100%Decisions logged
14 daysAvg. dispute resolution
HITRUSTCertified
SOC 2Type II audited
TPAs & Risk Bearing Providers
Third-Party Administrators, ACOs, & Captives
Managing delegated risk without the staff of a full health plan means DOFR rules need to route liability correctly, automatically, across every plan and provider group in the arrangement. That's what CAPS is built to do.
- Delegated Risk at Scale — Arrangements require health-plan-level accuracy on a leaner team.
- DOFR Disputes — Liability disputes consume staff time better spent elsewhere.
- Client Onboarding — Growing the book of business without proportionally growing the back office.
HealthOS CAPS30–60%Lower cost to operate
2–3xProductivity improvement
1Data core, every workspace
AutomatedDOFR liability routing
FAQ
Frequently Asked Questions.
Does HealthOS work for organizations outside health plans?
Yes. HealthOS is used by health plans, provider organizations, TPAs and risk-bearing entities, government programs, and life sciences partners, each connecting to the workspaces relevant to their operation.
Can a TPA manage multiple health plan clients on HealthOS?
Yes. CAPS is built to handle delegated risk arrangements across multiple clients on one data core, with DOFR rules routing liability correctly for each.
How do life sciences partners access HealthOS data?
Partners connect through AI PASS for real-time signals on utilization and outcomes, rather than relying on a periodic claims extract.
Get Started
See HealthOS in the context of your healthcare operations.
Bring your line of business and your hardest workflow — we'll show you how it runs on one intelligent platform.
