Systems and methods for determining indications of fraud in healthcare claims

Abstract

A method of controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, applying at least one rule to the information, wherein the at least one rule is adapted to determine indications of fraud and if fraud is indicated, flagging the claim, else recommending payment, wherein flagging of the claim or recommending payment occurs prior to payment. Also, a healthcare claim loss control system including a database having data related to healthcare claims and a loss control engine in communication with the database wherein the loss control engine accesses data corresponding to a healthcare claim when the claim is ready for payment, but before payment of the claim occurs and wherein the claim scoring engine applies at least one rule adapted to identify fraud and flags the claim for any indicated fraud before payment of the claim.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS [0001] This application claims the benefit of U.S. Provisional Application 60 / 694182 filed Jun. 27, 2005 entitled “SYSTEMS AND METHODS OF PROCESSING AND STORING HEALTHCARE DATA” which is incorporated herein in its entirety by reference.BACKGROUND OF THE INVENTION [0002] 1. Field of the Invention [0003] The invention relates to the field of healthcare claims and to systems and methods to improve loss control in payment of claims. [0004] 2. Description of the Related Art [0005] When an insured patient receives medical services and / or products from a health care provider, a health care claim typically results for reimbursement / payment of charges associated with the health care services. A health care claim frequently undergoes some type of internal processing by a payer, such as a health care insurance company. Once the processing is completed, the claim is forwarded for payment. Governmental regulations applying to the health care insurance indu...

AI Technical Summary

Benefits of technology

[0009] Various embodiments of the invention address the above-identified needs and limitations in existing loss control systems. Embodiments of the invention provide systems and methods to more effectively perform loss control in payment of a health care claim to provide cost saving benefits to the payer as well as to safeguard or improve the integrity of a health care claim system. At least certain embodiments of the invention provide loss control intervention at a point in the processing of a health care claim prior to payment of the claim. These embodiments provide the significant advantage of providing at least some loss control procedures before the claim is paid thereby reducing the value of claim loses which otherwise need to be recovered after payment of the claim.

[0010] At least certain other embodiments provide an efficient single point of contact between payers, providers, and other entities to more efficiently integrate information access and sharing. These aspects facilitate more efficient and timely processing of a health care claim to provide a payer with more effective loss control, provide payment to the provider in a timelier manner, and more effectively maintain integrity of an overall health care and health care payment system.

Problems solved by technology

For example, loss control can entail inhibiting payment on fraudulent claims.

However, certain limitations and difficulties have been identified in more effectively providing loss control for payment of health care claims.

For example, recovering losses after payment of a claim has occurred limits effectiveness for the payer to recover these losses.

In another aspect, while a variety of loss control services exist, for example fraud identification services and claim management services, a system for effectively coordinating these services has been lacking.

A further limitation is that the proper coding of a health care claim for services provided and possible fraud schemes can be relatively complex.

Thus, internal processing conducted for example by a payer, has limited ability to identify for example coding errors and fraudulent claims.

In addition, in certain implementations the pressures of handling a large number of claims each in a timely manner can be such that the return on investment for a payer to enact more thorough loss control processes is insufficient.

An additional limitations is that different clients often have different formatting of information and this further complicates efficient coordination of resources in controlling losses.

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