In recent years, it’s become more and common to see headlines touting health care providers performing medically unnecessary procedures in order to collect more insurance money. Not only is this sensational, it’s horrific and it’s important that we do what we can to prevent it. Insurance fraud detection is imperative to keeping insurers running smoothly and profitably.

Honing in on Fraud

Unnecessary procedures are extremely harmful to patients and cost Medicare and other insurance companies significant money. The key to healthcare fraud detection is to identify these incidences of fraud before a patient is injured. Oftentimes, the providers drawing attention for this are doing it far more frequently than their peers. However, utilizing analytics can assist in isolating the most common procedures being performed unnecessarily.  

How it Works

Data mining these common procedures and conditions can alert insurers to providers who appear to be performing an excess of certain procedures compared to their equals.  It is also quite helpful to look at the amount charged because a charge much lower than average could be indicative of a provider seeking to escape detection.

Once a potential identification has occurred, insurers can take steps to protect its members. These steps include:

  • Placing the provider on a watch list that alerts you to new claims
  • Cease auto-adjudication of all of the provider’s claims
  • Audit all of the provider’s claims
  • Request pertinent medical records
  • Implore SIU investigators to look into fraudulent activity
  • Take administrative or legal action

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