NEAR REAL-TIME HEALTHCARE FRAUD DETECTION
First Claim
1. A method, comprising:
- storing, by one or more computer devices of a healthcare fraud management system, a plurality of rules for detecting healthcare fraud;
receiving, by the one or more computer devices, a healthcare claim involving a provider and a beneficiary;
obtaining, by the one or more computer devices, other healthcare fraud information associated with the provider or the beneficiary;
selecting, by the one or more computer devices, rules, from the plurality of rules, based on information associated with the claim, information associated with the provider or the beneficiary, and the other healthcare fraud information;
processing, by the one or more computer devices, the healthcare claim using the selected rules to generate a fraud score; and
outputting, by the one or more computer devices and prior to payment of the healthcare claim, information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim.
1 Assignment
0 Petitions
Accused Products
Abstract
A healthcare fraud management system is configured to store multiple rules for detecting healthcare fraud, receive a healthcare claim involving a provider and a beneficiary, and obtain other healthcare fraud information associated with the provider or the beneficiary. The healthcare fraud management system is further configured to select rules, from the multiple rules, based on information associated with the claim, information associated with the provider or the beneficiary, and the other healthcare fraud information. The healthcare fraud management system is also configured to process the healthcare claim using the selected rules to generate a fraud score, and output, prior to payment of the healthcare claim, information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim.
105 Citations
20 Claims
-
1. A method, comprising:
-
storing, by one or more computer devices of a healthcare fraud management system, a plurality of rules for detecting healthcare fraud; receiving, by the one or more computer devices, a healthcare claim involving a provider and a beneficiary; obtaining, by the one or more computer devices, other healthcare fraud information associated with the provider or the beneficiary; selecting, by the one or more computer devices, rules, from the plurality of rules, based on information associated with the claim, information associated with the provider or the beneficiary, and the other healthcare fraud information; processing, by the one or more computer devices, the healthcare claim using the selected rules to generate a fraud score; and outputting, by the one or more computer devices and prior to payment of the healthcare claim, information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10)
-
-
11. A system, comprising:
-
one or more memory devices to store a plurality of rules for detecting healthcare fraud; and one or more processors to; receive a healthcare claim involving a provider and a beneficiary; obtain other healthcare fraud information associated with the provider or the beneficiary; select a subset of rules, of the plurality of rules, based on information associated with the healthcare claim, information associated with the provider or the beneficiary, and the other healthcare fraud information; process the healthcare claim using the subset of rules to generate a plurality of alarms; process the plurality of alarms to generate a fraud score for the healthcare claim; and output information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim. - View Dependent Claims (12, 13, 14, 15, 16, 17, 18, 19)
-
-
20. A computer-readable medium, comprising:
one or more instructions that, when executed by at least one processor of a healthcare fraud management system, cause the at least one processor to; store a plurality of rules for detecting healthcare fraud, receive a healthcare claim involving a provider and a beneficiary, obtain other healthcare fraud information associated with the provider or the beneficiary, select a subset of rules, of the plurality of rules, based on information associated with the healthcare claim, information associated with the provider or the beneficiary, and the other healthcare fraud information, process the healthcare claim using the subset of rules to generate a plurality of alarms, process the plurality of alarms to generate a fraud score for the healthcare claim, and output, prior to payment of the healthcare claim, information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim.
Specification