CASE MANAGEMENT OF HEALTHCARE FRAUD DETECTION INFORMATION

• US 20130006656A1
• Filed: 06/28/2012
• Published: 01/03/2013
• Est. Priority Date: 06/30/2011
• Status: Abandoned Application

• Current Assignee: Verizon Patent and Licensing Incorporated (Verizon Communications Inc.)
• Original Assignee: Verizon Patent and Licensing Incorporated (Verizon Communications Inc.)
• Inventors: VAN ARKEL, John H., WAGNER, James J., SCHWEYEN, Corrine L., MAHONE, Saralyn M., TADA, David D., CURTIS, Terrill J., HAGINS, Scott
• Application Number:
  US13/536,460
• Publication Number:
  US 20130006656A1
• Time in Patent Office: Days
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management

Abstract

A healthcare fraud management system receives healthcare claims associated with a particular entity, selects rules, from a plurality of rules for detecting healthcare fraud, based on information associated with the healthcare claims, and processes the healthcare claims using the selected rules to generate alarms. The healthcare fraud management system prioritizes, based on the generated alarms, healthcare information associated with the particular entity in relation to healthcare information associated with other entities. The healthcare fraud management system provides for display, prior to payment of the healthcare claims, the prioritized healthcare information associated with the particular entity and the other entities.

Claims

1. A method, comprising:

receiving, by one or more computer devices of a healthcare fraud management system, healthcare claims associated with a particular entity;

selecting, by the one or more computer devices, rules, from a plurality of rules for detecting healthcare fraud, based on information associated with the healthcare claims;

processing, by the one or more computer devices, the healthcare claims using the selected rules to generate alarms;

prioritizing, by the one or more computer devices and based on the generated alarms, healthcare information associated with the particular entity in relation to healthcare information associated with other entities; and

providing for display, by the one or more computer devices and prior to payment of the healthcare claims, the prioritized healthcare information associated with the particular entity and the other entities.

2. The method of claim 1, where the prioritized healthcare information includes one or more of:

a list of names associated with the particular entity and the other entities,

case identifications associated with the particular entity and the other entities,

specialties associated with the particular entity and the other entities,

costs associated with the particular entity and the other entities, and

procedures associated with the particular entity and the other entities.

3. The method of claim 1, further comprising:

receiving selection of the healthcare information associated with the particular entity; and

providing for display information associated with the healthcare claims of the particular entity.

4. The method of claim 3, where the information associated with the healthcare claims of the particular entity includes one or more of:

information associated with the particular entity,

a list of the alarms associated with the particular entity, and

a list of the healthcare claims associated with the particular entity.

5. The method of claim 3, where the information associated with the healthcare claims of the particular entity includes:

a geographical map associated with the particular entity,

an indication of a location of an alert associated with the particular entity, the indication being provided on the geographical map, and

a name, an address, and billing information associated with the particular entity.

6. The method of claim 1, where the plurality of rules include at least one of:

provider-specific rules;

provider type-specific rules;

beneficiary-specific rules;

procedure frequency-specific rules;

geographical dispersion of services-specific rules;

single claim analysis-related rules;

auto summation of provider procedure time-specific rules;

suspect beneficiary ID theft-specific rules;

alert on suspect address-specific rules;

inconsistent relationship-specific rules;

excessive cost-specific rules;

rules that identify fraudulent therapies;

or rules that identify a gang visit fraud scheme.

7. The method of claim 1, where processing the healthcare claims comprises:

processing the healthcare claims, in parallel, using the selected rules to generate a plurality of alarms, and

sorting the plurality of alarms into a plurality of groups based on attributes of the healthcare claims, where each of one or more of the plurality of groups includes alarms from the healthcare claims.

8. The method of claim 1, where the prioritized healthcare information is provided for display to a clearinghouse or a claims processor in near real-time.

9. A healthcare fraud management system, comprising:

one or more memory devices to store a plurality of rules for detecting healthcare fraud; and

one or more processors to;

receive healthcare claims associated with a particular entity,

select rules, from the plurality of rules, based on information associated with the healthcare claims,

process the healthcare claims using the selected rules to generate alarms,

prioritize, based on the generated alarms, healthcare information associated with the particular entity in relation to healthcare information associated with other entities, and

provide for display, prior to payment of the healthcare claims, the prioritized healthcare information associated with the particular entity and the other entities.

10. The system of claim 9, where the prioritized healthcare information includes one or more of:

a list of names associated with the particular entity and the other entities,

case identifications associated with the particular entity and the other entities,

specialties associated with the particular entity and the other entities,

costs associated with the particular entity and the other entities, and

procedures associated with the particular entity and the other entities.

11. The system of claim 9, where the one or more processors are further to:

receive selection of the healthcare information associated with the particular entity, and

provide for display information associated with the healthcare claims of the particular entity.

12. The system of claim 11, where the information associated with the healthcare claims of the particular entity includes one or more of:

information associated with the particular entity,

a list of the alarms associated with the particular entity, and

a list of the healthcare claims associated with the particular entity.

13. The system of claim 11, where the information associated with the healthcare claims of the particular entity includes:

a geographical map associated with the particular entity,

an indication of a location of an alert associated with the particular entity, the indication being provided on the geographical map, and

a name, an address, and billing information associated with the particular entity.

14. The system of claim 9, where the plurality of rules include at least one of:

provider-specific rules;

provider type-specific rules;

beneficiary-specific rules;

procedure frequency-specific rules;

geographical dispersion of services-specific rules;

single claim analysis-related rules;

auto summation of provider procedure time-specific rules;

suspect beneficiary ID theft-specific rules;

alert on suspect address-specific rules;

inconsistent relationship-specific rules;

excessive cost-specific rules;

rules that identify fraudulent therapies;

or rules that identify a gang visit fraud scheme.

15. The system of claim 9, where, when processing the healthcare claims, the one or more processors are further to:

process the healthcare claims, in parallel, using the selected rules to generate a plurality of alarms, and

sort the plurality of alarms into a plurality of groups based on attributes of the healthcare claims, where each of one or more of the plurality of groups includes alarms from the healthcare claims.

16. The system of claim 9, where the prioritized healthcare information is provided for display to a clearinghouse or a claims processor in near real-time.

17. 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 healthcare claims associated with a particular entity,

select rules, from the plurality of rules, based on information associated with the healthcare claims,

process the healthcare claims using the selected rules to generate alarms,

prioritize, based on the generated alarms, healthcare information associated with the particular entity in relation to healthcare information associated with other entities, and

provide for display, prior to payment of the healthcare claims, the prioritized healthcare information associated with the particular entity and the other entities.

18. The computer-readable medium of claim 17, where the prioritized healthcare information includes one or more of:

a list of names associated with the particular entity and the other entities,

case identifications associated with the particular entity and the other entities,

specialties associated with the particular entity and the other entities,

costs associated with the particular entity and the other entities, and

procedures associated with the particular entity and the other entities.

19. The computer-readable medium of claim 17, further comprising:

one or more instructions that, when executed by the at least one processor, cause the at least one processor to;

receive selection of the healthcare information associated with the particular entity, and

provide for display information associated with the healthcare claims of the particular entity.

20. The computer-readable medium of claim 19, where the information associated with the healthcare claims of the particular entity includes one or more of:

information associated with the particular entity,

a list of the alarms associated with the particular entity, and

a list of the healthcare claims associated with the particular entity.

21. The computer-readable medium of claim 19, where the information associated with the healthcare claims of the particular entity includes:

a geographical map associated with the particular entity,

an indication of a location of an alert associated with the particular entity, the indication being provided on the geographical map, and

a name, an address, and billing information associated with the particular entity.