Our solutions - Transforming Healthcare Program Integrity
Our integrated suite of solutions combines advanced AI with deep healthcare expertise to deliver comprehensive program integrity - from early detection of inappropriate utilization to precise payment reconciliation across complex value-based care models.
Sentinel
Claims Integrity
Ensure claims are billed correctly and abide by payment integrity rules and regulations through AI-powered investigative agents that understand Medicare policies and uncover fraud, waste, and abuse.
- Advanced pattern detection across utilization, billing, provider networks, and emerging fraud schemes
- Smart workflows enabling rapid intervention and program optimization
- Proactive monitoring with risk scoring and clinical review integration
- End-to-end case management from alert to resolution with proven impact metrics
Accepted Data Sources:
- X12 837
- BCDA API
- CCLF
- ADT
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.
- Detailed MSSP and ACO REACH performance metrics with drill-down capabilities
- Transparent benchmarking methodology showing exactly how you compare to peers
- Root cause analysis connecting utilization patterns to performance outcomes
- Forward-looking projections based on current trends and historical patterns
Scope
Risk Adjustment & Quality Integrity
Navigate Medicare Advantage operations with confidence through comprehensive risk adjustment reconciliation that ensures accurate payments, protects against RADV audits, and recovers legitimate revenue.
- Advanced reconciliation engine ingesting and processing data across multiple CMS systems
- Risk Adjustment reconciliation through RAPS, EDS, MARx, MAO-004, and other payment files
- Higher payment accuracy with fewer missing risk factors and faster reconciliation
- Stronger compliance through robust documentation and error detection
Our approach - Precision meets innovation
We combine cutting-edge AI technology with deep healthcare domain expertise to deliver solutions that protect program integrity while advancing quality care delivery.
- Proactive. Our AI-powered monitoring identifies potential issues before they impact your organization, enabling early intervention and prevention.
- Precise. We ensure accurate payment reconciliation across complex healthcare programs through sophisticated rule processing and validation.
- Comprehensive. From utilization monitoring to payment accuracy, our integrated approach provides end-to-end program integrity solutions.
- Compliant. We maintain rigorous compliance standards while adapting to evolving healthcare regulations and payment models.
- Collaborative. We work closely with our partners to understand their unique challenges and deliver tailored solutions that drive measurable results.
- Innovative. Our continuous investment in R&D ensures we stay ahead of emerging healthcare challenges and payment model complexities.
Partner 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