fraud detection

reduce the costs of fraud, waste, and abuse

Get the Fact Sheet

Those who seek to commit healthcare fraud and abuse are continually adapting. Often, they fly just under the radar with billing behavior that's not quite bad enough to be identified by claim systems looking at just a single provider or within just one payer's claim patterns. At the same time, the increasingly complex healthcare landscape presents fresh opportunities for new or continuing areas of wasteful and erroneous billing.

Verscend Technologies Fraud Detection solution combines advanced analytics and clinical investigative review to deliver actionable case referrals to cost containment staff and special investigations units (SIU). The result is pre- and post-pay protection from aberrant billing and known and emerging fraud schemes. Clients who self-report savings to us, per their process and accounting practices, report savings of between $0.40 and $1.70 PMPM.

features

  • Highly customizable rules, data feeds and user experience
  • Predictive analytics, link-analysis and multi-variant models
  • Profiling and scoring of high-risk providers and fraud schemes
  • Clinical review and validation of all suspect billing activity
  • Fully vetted allegations sent directly to your SIU
  • Optional case tracking workflow tool

benefits

  • Improve prevention and recoveries
  • Reduce the time and effort needed to validate fraud allegations
  • Reduce false-positive allegations and open more cases--up to 80% case open rates
  • Comply with state Medicaid program integrity requirements
  • Simplify complex case tracking

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