Waste accounts for a considerable portion of annual health care costs in the US, most of it due to fraud and overbilling. (According to some, $1 out of every $7 spent on Medicare is lost to fraud.) Because the incentive to defraud a multi-trillion dollar system is quite high, the methods are many, sophisticated, and varied. MediClaims detects all known methods of fraud:
– Billing for services, procedures, or supplies not provided
– Misrepresenting what was provided and when, or the identity of the recipient
– Performing unnecessary procedures and tests
– Unbundling claims (billing separately for procedures covered by a single fee)
– Double-billing the same service
– Up-coding (charging for a more complex procedure than the one performed)
– Miscoding (using a code that does not apply to the service provided)
– Mismatch between services billed and plan benefits
