For health-plan leaders - Medical costs are rising. Find where—and what to investigate next.

When spending exceeds expectations, a total isn’t an explanation. Falcon helps your team investigate utilization, provider billing, and data quality together, with supporting evidence to decide where to act.

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Today

Finance sees the variance. Operations has the utilization reports. Payment integrity has its own leads. Your team has to reconcile their explanations before deciding what needs attention.

With Falcon

Investigate the spending change against the underlying claims, provider patterns, and data completeness. Preserve the evidence in case files and reports, then schedule monitoring to follow what changes.

An illustrative investigation

What changed in medical spending this quarter?

01

Verify the spending picture

Check claims completeness and compare utilization and provider patterns. Distinguish a real change from a late file or an incomplete input.

02

Investigate the billing signals

Review unusual claims against peer comparisons, provider research, and Medicare coverage rules. An anomaly is a lead to investigate, not a finding of fraud.

03

Act and follow the results

Prepare supported case files for review and schedule repeatable analysis. Use Scope to investigate encounter, enrollment, and payment discrepancies that may also put MA revenue at risk.

Sentinel investigation leads with billing signals, dollar context, peer comparisons, and review status
Sentinel keeps the billing signal, dollar context, and review priority together. Provider names and NPIs in this product image are anonymized. The investigation above is illustrative, not a customer result.

Bring the performance question your team needs to answer.

We’ll discuss your data and workflow, then show the relevant Falcon capabilities. Your team reviews the evidence and decides what to do next.

See a health-plan workflow