Fraud, Waste and Abuse

Fraud, Waste and Abuse

  • Proprietary database-driven technology analyzes providers with suspect billing activity across all payer data
  • Data mining systems flag qualified cases for investigation
  • Data-driven predictive analytics
  • Custom rules and alerts that are driven by client-specific workflow and payment policies
  • Experienced investigators track, analyze and validate suspect claims
The most common fraud schemes include:
  • Upcoding and misrepresentation of services (e.g., unbundling)
  • Stolen physician/patient identities
  • Unnecessary diagnostic services
  • Exploitation of benefit plans
  • Services not rendered (e.g., false claims/charges)
  • Kickback arrangements among providers