Fraud Detection Solutions
Abuse stops here
Abuse stops here
The sheer volume of claims health insurance companies need to process and the complexity of the associated medical records means that payouts are made without performing a thorough investigation of every claim. Correspondingly, this industry is especially susceptible to fraud. Timely detection and prevention of fraud and abuse in health insurance can help recover enormous amounts of money.
Our health insurance fraud detection solution analyzes claims to determine normal behavior patterns and detect possible fraud and abuse. The system combines statistical and machine learning techniques with heuristic calculations grounded in a solid understanding of the medical domain to detect anomalous situations.
We are pleased to provide you with a personalized software demonstration so that you can see the software in action. A Megaputer representative will speak with you about your project, your concerns, and answer questions about the software. The demonstration takes place over the web, along with an optional voice line. No hassle, no commitment.
The solution uses several technological approaches to identify anomalies:
The solution combines multiple data analysis scenarios to identify specific deviations in the behavior of individual providers or patients. For example, it can reveal cases where a provider works more than 24 hours a day, or when patients brought in by an ambulance have no record of receiving any medical treatment.
Based on the analysis of the bulk of claims, the solutions determines normal behavior patterns for providers of different specialties treating various conditions and identifies anomalous patterns. This enables the user to detect possible abuse even without knowing the exact schemes being used to defraud the system.
Going beyond claims data analysis, the solution can run the analysis of the associated patient medical records to audit the accuracy of the performed medical coding. It reveals discrepancies between the codes seen in the claim and the treatment performed. This capability is described more in the Automated Medical Coding section.
By aggregating all discovered irregularities the solution identifies providers that have systematic anomalies in their behavior. Frequently, these providers are being singled out by more than one analysis scenario included in the solution. The system facilitates further investigation of suspect providers to reveal the actual abuse schemes.