Method for detecting and preventing fraudulent healthcare claims

• US 10,002,391 B1
• Filed: 10/11/2011
• Issued: 06/19/2018
• Est. Priority Date: 10/11/2010
• Status: Active Grant

• Current Assignee: Pionetechs, Inc.
• Original Assignee: Pionetechs, Inc.
• Inventors: Kusens, Bruce Howard
• Primary Examiner(s): Baird, Edward J
• Application Number:
  US13/270,255
• Time in Patent Office: 2,443 Days
• Field of Search: 705 2
• CPC Class Codes: G06Q 40/08 Insurance

Abstract

A computer implement method that assist healthcare payers in identifying potentially fraudulent claims and which requests confirmation preferably from a healthcare provider or patient of services rendered by the healthcare provider or products received by the patient. Confirmation of equipment and services can occur at different times in the settlement process including, but not limited to, prior to payments being made to health care providers.

Claims

1. A computer implemented method for automatically detecting whether a healthcare claim is fraudulent after the healthcare claim has been electronically submitted for payment, the method comprising:

(a) receiving an electronic healthcare claim for payment from a healthcare provider by a healthcare claim integrity computer system of a healthcare payer, the healthcare claim integrity computer system including an analytics engine in electronic communication with an electronic data warehouse, the analytics engine programmed to determine the likelihood of potential fraud and abuse for a submitted healthcare claim and is programmed to consider data points from the submitted healthcare claim in future potential fraud and abuse determinations by the analytics engine;

(b) importing electronic healthcare claim data from the received electronic healthcare claim into the analytics engine, said healthcare claim data identifying one or more services provided to a patient or one or more products received by a patient from the healthcare provider;

(c) electronically determining by the analytics engine based on programmed detection criteria and the imported electronic healthcare claim data whether or not the received a healthcare claim is suspect or fraudulent;

(d) automatically diverting for confirmation by the healthcare claim integrity computer system any received healthcare claim determined to be suspect or fraudulent by the analytics engine in step (c);

(e) for healthcare claims diverted in step (d) electronically contacting the healthcare provider or the patient who received the one or more services or products through an automated system of the healthcare claim integrity computer system;

(f) electronically determining by the healthcare claim integrity computer system whether one or more services or products listed in the healthcare claim were actually provided by the healthcare provider;

(g) requesting, by the healthcare claim integrity computer system, electronic confirmation from the healthcare provider or patient contacted in step (e) as to whether the one or more services or products listed in the healthcare claim were received; and

(h) (i) automatically initiating an electronic intercept of the healthcare claim by the analytics engine for further investigation of the healthcare claim where the healthcare provider or patient fails to confirm that one or more services or products were received after a certain period of time;

or (ii) electronically receiving, by the healthcare claim integrity computer system, a positive electronic acknowledgment from the healthcare provider or patient confirming that the one or more services or products were received and updating an electronic data warehouse that the healthcare claim was reviewed;

(i) automatically updating the programmed detection criteria used by the analytics engine when reviewing future healthcare claims by the healthcare claim integrity computer system based on data points from the submitted healthcare claim and data saved concerning confirmation of the submitted healthcare claim or an intercept of the submitted healthcare claim; and

(j) updating an electronic data warehouse by the healthcare claim integrity system indicating that the healthcare claim is not suspect or fraudulent for a healthcare claim receiving a positive acknowledgment in step (h)(ii) or that a claim intercept was initiated in step (h)(i).

2. The computer implemented method of claim 1 wherein said step of contacting a healthcare provider or patient comprises automatically contacting the healthcare provider or patient through phone, email, SMS or instant messaging.