Transforming Healthcare Program Integrity Through AI
At Falcon Health, we're on a mission to revolutionize healthcare program integrity through advanced analytics and intelligent monitoring. Our technology ensures the right care is incentivized, detects potential issues early, and maintains payment accuracy. We're building a future where healthcare works better for everyone by protecting program integrity across care delivery and reimbursement.
Our comprehensive approach - Three Dimensions of Program Integrity
Creating lasting change in healthcare requires both proactive monitoring and precise payment solutions. Our groundbreaking platforms work in harmony to elevate healthcare delivery:
- Pulse - Network Integrity. Comprehensive provider utilization and value-based care performance monitoring for network optimization. Estimate member assignment to each provider, track where utilization is leaking, and analyze Medicare utilization patterns over time. Find the best providers that match your ACO or risk-bearing organization's performance profile. Business development with real science.
- Sentinel - Claims Integrity. Ensure claims are billed correctly and abide by payment integrity rules through AI-powered investigative agents. Our platform understands Local Coverage Determinations and billing policies, identifies anomalous patterns across three data pillars (internal datasets, digital footprint, and public records), and provides deep investigation capabilities to uncover fraud, waste, and abuse.
- Scope - Risk Adjustment & Quality Integrity. Navigate Medicare Advantage operations with confidence through advanced risk adjustment reconciliation. We process all CMS data files flowing between CMS, State Governments, and payers—ensuring risk-adjusted conditions are captured correctly, payments are fair and accurate, and you're protected from RADV audit exposure while recovering legitimate revenue.
Why Falcon
Our AI-powered platforms deliver measurable results across three critical dimensions:
- Network Optimization & Value-Based Care. Our Pulse platform delivers comprehensive provider utilization and value-based care performance monitoring. Estimate member assignment to each provider, track where utilization is leaking, and analyze Medicare utilization patterns over time to find the best providers for your network. This scientific approach to business development helps you build networks that drive quality outcomes while controlling costs in ACOs and other value-based arrangements.
- Claims Integrity & FWA Detection. Our Sentinel platform uses AI-powered investigative agents to ensure claims are billed correctly and abide by payment integrity rules. By analyzing three data pillars—internal datasets, digital footprint, and public records—we identify anomalous billing patterns and understand Local Coverage Determinations to uncover fraud, waste, and abuse. This comprehensive approach protects your organization through deep investigation capabilities and early intervention.
- Risk Adjustment & Quality Reconciliation. Our Scope platform eliminates revenue leakage by automating complex Medicare Advantage operations across CMS data files. We navigate intricate payment rules from Risk Adjustment to Quality Metrics reconciliation with unmatched accuracy. By processing data between CMS, State Governments, and payers, we ensure fair payments, protect against RADV audit exposure, and recover legitimate revenue while maintaining ironclad compliance.
Discover Our Solutions
Learn more about Pulse, Sentinel, and Scope - our innovative platforms transforming network optimization, claims integrity, and payment accuracy.
View Our SolutionsPartner with Falcon Health and join us in protecting the integrity of healthcare through intelligent monitoring.
Our offices
- Palo Alto, CA
Corporate HQ - Atlanta, GA
Technology Branch