Fraud Detection

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

Warnings and fraud detection

– 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