Health Insurance Fraud Solution
Health Insurance Fraud
Health Insurance Fraud can be committed at various points in the claim transaction by different parties inclusive of claimants, policyholders, third-party claimants and the professionals who provide services to claimants. Some instances of fraud include:
- Ineligible members and/or dependents
- Alterations to enrolment forms
- Concealing pre-existing conditions
- Failure to report other coverage
- Prescription drug fraud
- Failure to disclose claims that were a result of a work related injury
- Claims submitted by bogus physicians
- Billing for services not rendered
- Billing for higher level of services
- Diagnosis or treatments that are outside the scope of practice
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Alterations to claims submissions
The health insurance industry suffers tremendous losses globally and the resulting impact is higher premiums. For example, in the U.S. alone health insurance fraud was estimated to cost $68 billion. (National Health Care Anti-Fraud Association, 2008)
Combating Fraud
The methods being used in many health insurers lacks the sophistication to stay ahead of the threat. Relying solely on adjudicators is risky and likely to be futile resulting in greater expenditure and marginal results. Implementing software that can identify abnormal claim patterns increases the likelihood of detecting fraud significantly.
Every $2 million invested in fighting health-care fraud returns $17.3 million in recoveries, court-ordered judgments, plus bogus claims that weren’t paid and other anti-fraud savings. (National Health Care Anti-Fraud Association, 2008)
SymSure Health Insurance Fraud Monitoring
The solution employs a combination of business rules and predictive analytics to detect fraudulent claims. SymSure integrates seamlessly requiring no changes to existing business systems in the organization.
All claims are examined against business rules in addition to advanced analytics to detect anomalies. Alerts are generated and distributed to the business process owners covering all stages of the process, from enrollment to payment.
Combating Fraud
The methods being used in many health insurers lacks the sophistication to stay ahead of the threat. Relying solely on adjudicators is risky and likely to be futile resulting in greater expenditure and marginal results. Implementing software that can identify abnormal claim patterns increases the likelihood of detecting fraud significantly.
Every $2 million invested in fighting health-care fraud returns $17.3 million in recoveries, court-ordered judgments, plus bogus claims that weren’t paid and other anti-fraud savings. (National Health Care Anti-Fraud Association, 2008)
SymSure Health Insurance Fraud Monitoring
The solution employs a combination of business rules and predictive analytics to detect fraudulent claims. SymSure integrates seamlessly requiring no changes to existing business systems in the organization.
All claims are examined against business rules in addition to advanced analytics to detect anomalies. Alerts are generated and distributed to the business process owners covering all stages of the process, from enrollment to payment.