UNIQUE FRAUD PREVENTION TOOL
Q - Why doesn’t the insurance company monitor Fraud for us?
Although insurance companies provide a great deal of services to employee-funded plans, there is no advantage for them to protect plans from fraud.
Under ERISA, the plan sponsor is the beneficiary of fraud reduction or recovery, so carriers and administrators have minimal incentive to invest in reducing fraud. Therefore, employers carry the burden of protecting the plans, not the insurance company. Furthermore, insurance rates increase based on what was spent the previous year, so any fraud loss prevention reduces the cost of reinsurance the following year.
Who We Serve
- Self Insured Plans
- Taft-Hartley Plans
- National Divisional Companies
- School Districts
- Governments
Affordable Solutions with Guaranteed Results
Fraud or inappropriate health claims can cost self-insured employers between $1,085 and $1,860 per year. In some cases, investigating such instances of fraud can cost even more money and – most importantly – time.
Make the Most of Your Health Plan
We utilize existing payment networks to prevent, detect and deter fraud and medical identity theft.
The costs to set-up, implement, and customize our system are a fraction of other fraud protections.
Our clients see immediate results as soon as the system is implemented and can continue to monitor and measure effectiveness the longer it’s in use.
Based on accepted estimates of fraud and abuse, for each 1% of fraud that our services prevent, the ROI is
more than 125%.
A significant advantage of self-insured plans is the increased ability to manage healthcare costs. The real-time power of the payment networks – available to all health plans – helps prevent, detect and deter fraud and benefit identity thefts in your health plan. These hidden expenses cost health plans and member between 3% and 20% of costs each year.
Self-Insured Employers Also Saw…
- Reduced claims for services with no physician authorization
- Reduced billing for phantom patients, per-physician billings
Step 1 - Verify Transactions Using Identification Cards
To get started, We issue and manage an identification card. These cards are distributed to all members of the health insurance plan. They can be read at any standard credit card terminal and deliver real-time information to our customers. We educate staff within the health plan on how to use the cards.
The cards have the following features:
- No protected health information
- No financial risk
- Scanned at each visit to healthcare provider using the same terminal they use for credit card transactions.
Step 2 - Gather and Process Information at the Point of Care
When a beneficiary visits a provider, the front office staff swipes the identification card in the same terminal used for debit or credit card transactions. A pre-selected code is also entered.
Each card swipe carries data we use in anti-fraud activities:
- Card Identification
- Owner and location of the swipe terminal
- Merchant code of the terminal
- Transaction code entered
- Time Stamp
Our business rules engine then processes this information in real time to determine fraud-related data, including:
- Is this card terminal in our database of providers?
- Has the card been lost or stolen? Are there any restrictions?
- Has the card been swiped at another location?
- Does the member already have a prescription for a Class II drug?
- Who is the payer of record for this beneficiary?
Depending upon client needs, other real-time analyses can be created.
Report mismatches on the portal dashboard as soon as they are identified and long before the claim is ever paid.
Step 3 - Automatically Verify Claims with our Services
When a claim is received from the provider for a clinic visit, prescription, or medical device transaction, we match it to the data received from the card network. Because of our real-time card checks, some claims can be rejected outright. Others can be suspended pending further review.
We provide a portal to give access to real-time and historical data. Reports and exceptions can be delivered with a simple point-and-click interface.
- The portal is available for use by all users authorized by the customer (doctors, pharmacists, customers, and members), with access controllable by the customer
- Real-time analysis and alerts are standard
- Users generate custom reports depending upon their level of security
- Administrative functions, such as reporting and replacing lost or stolen ID cards
GOVERNMENT PROGRAMS
MEDICARE/MEDICAID FRAUD
756%
Estimated ROI for Verification of Claims for Federal Government (Medicare)
660%