Systems and methods for reducing medical claims fraud

• US 9,727,919 B2
• Filed: 11/14/2011
• Issued: 08/08/2017
• Est. Priority Date: 11/14/2011
• Status: Active Grant

• Current Assignee: Identity Theft Guard Solutions Inc. (ZeroFox Holdings, Inc.)
• Original Assignee: Identity Theft Guard Solutions Inc. (ZeroFox Holdings, Inc.)
• Inventors: Gregg, Robert S., Kane, Christopher Allen, Arevalo, Christine Clementina
• Primary Examiner(s): Gort, Elaine
• Assistant Examiner(s): Go, John
• Application Number:
  US13/296,159
• Publication Number:
  US 20130124223A1
• Time in Patent Office: 2,094 Days
• Field of Search: 726 7
• CPC Class Codes: G06F 21/6245 Protecting personal data, e.g. for financial or medical purposes
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/0185 Product, service or business identity fraud
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

Various embodiments of the present disclosure may be comprised of systems and methods for reducing fraudulent use of a medical identity to obtain medical goods or services. Identification information may be received for a medical insurance account of a medical consumer. Medical claims data associated with the medical insurance account may be received, and the medical claims data may be transmitted to the medical consumer. A confirmation status may be received from the medical consumer for the medical claims data.

Claims

1. A method comprising:

receiving an enrollment request from a hand-held personal digital assistant operated by a medical consumer for a medical fraud alert service;

in response to receiving the enrollment request, authenticating an identity of the medical consumer by providing to the hand-held personal digital assistant operated by the medical consumer details for a plurality of medical goods or services, wherein a portion of the plurality of medical goods or services are actual goods or services provided to the medical consumer and a portion are fictitious medical goods or services;

in response to the providing to the hand-held personal digital assistant operated by the medical consumer details for the plurality of medical goods or services, receiving a response from the hand-held personal digital assistant operated by the medical consumer indicating which of the plurality of medical goods or services are actual goods or services and which are fictitious goods or services;

receiving by a cloud-based fraud prevention server from a provider of medical insurance, medical billing, diagnostic or procedural codes associated with a medical insurance account of the medical consumer, the medical billing, diagnostic or procedural codes further comprising medical goods or medical services previously provided to the medical consumer by a provider of the medical goods or the medical services and submitted to the provider of medical insurance by the provider of the medical goods or the medical services;

analyzing by the cloud-based fraud prevention server the medical billing, diagnostic or procedural codes by comparing a frequency the provider cites a particular diagnosis against an average frequency of other providers citing the particular diagnosis;

determining if the frequency the provider cites the particular diagnosis meets or exceeds a predefined threshold for the average frequency of the other providers citing the particular diagnosis;

if the frequency exceeds the predefined threshold for the average frequency of the other providers citing the particular diagnosis, notifying the provider of medical insurance about potential fraud;

analyzing by the cloud-based fraud prevention server the medical billing, diagnostic or procedural codes by determining if the medical insurance account has been used to obtain a prescription from multiple providers of medical goods or medical services;

if the medical insurance account has been used to obtain the prescription from the multiple providers of medical goods or medical services, notifying the provider of medical insurance about potential fraud;

automatically securely transmitting by the cloud-based fraud prevention server the medical billing, diagnostic or procedural codes in the form of a text message to the hand-held personal digital assistant operated by the medical consumer; and

receiving by the cloud-based fraud prevention server a confirmation status from the hand-held personal digital assistant operated by the medical consumer for the medical billing, diagnostic or procedural codes;

determining if the confirmation status indicates potential fraud; and

if the confirmation status indicates potential fraud, notifying the provider of medical insurance.

2. The method of claim 1, wherein the medical insurance account comprises one or more of a name and address of the medical consumer, a name of an insurance provider, a policy number, a group number, and a member number.

3. The method of claim 1, wherein the medical billing, diagnostic or procedural codes comprise one or more of a name and address of a provider of the medical goods or services, a location where the medical goods or services were provided, a description of the medical goods or services, and a date that the medical goods or services were provided.

4. The method of claim 1, wherein transmitting the medical billing, diagnostic or procedural codes to the medical consumer comprises alerting the medical consumer that medical claims data have been received.

5. The method of claim 1, further comprising transmitting the medical billing, diagnostic or procedural codes to the medical consumer by sending an electronic mail message, a text message, a message delivered via a social media website, a telephone call, or a letter to the medical consumer.

6. The method of claim 1, wherein receiving confirmation status from the medical consumer comprises receiving one of:

confirmation from the medical consumer that the medical billing, diagnostic or procedural codes are accurate;

confirmation from the medical consumer that the medical billing, diagnostic or procedural codes are inaccurate;

or

notification that the medical consumer is unable to determine the accuracy of the medical billing, diagnostic or procedural codes.

7. The method of claim 6, further comprising initiating further communications with the medical consumer when the medical consumer confirms that the medical billing, diagnostic or procedural codes are inaccurate or is unable to determine the accuracy of the medical billing, diagnostic or procedural codes.

8. The method of claim 6, further comprising notifying a provider of the medical insurance account when the medical consumer confirms that the medical billing, diagnostic or procedural codes are inaccurate or is unable to determine the accuracy of the medical billing, diagnostic or procedural codes.

9. The method of claim 1, wherein receiving confirmation status from the medical consumer comprises receiving notification that the medical consumer has viewed the medical billing, diagnostic or procedural codes.

10. The method of claim 1, wherein receiving confirmation status from the medical consumer comprises receiving an access request from the medical consumer to access a website containing the medical billing, diagnostic or procedural codes.

11. The method of claim 1, further comprising notifying a provider of the medical insurance account after a determination has been made that the medical billing, diagnostic or procedural codes may be fraudulent.

12. The method of claim 1, further comprising transmitting the confirmation status to a provider of the medical insurance account.

13. The method of claim 1, wherein medical goods or services comprises direct interaction with doctors, dentists, psychologists, therapists, chiropractors, nurses, assistants, hygienists, technicians, trainers, nutritionists, emergency medical technicians, social workers, and like health practitioners and professionals;

prescription medications;

laboratory services;

high technology diagnostic services, tests, and procedures;

transportation by ambulance;

blood and blood products;

durable medical equipment and associated supplies;

eyeglasses and corrective lenses;

external prosthetic, orthotic and corrective devices;

internal medical devices; and

the like.

14. The method of claim 1, further comprising transmitting a reminder to the medical consumer when the medical consumer fails to confirm the confirmation status of the medical billing, diagnostic or procedural codes after a predetermined period of time.

15. The method of claim 1, further comprising:

notifying the medical consumer of abnormal activity on the medical insurance account associated with the medical consumer;

requesting confirmation of the medical billing, diagnostic or procedural codes from the medical consumer; and

receiving a response to the confirmation request from the medical consumer.

16. The method of claim 1, wherein the confirmation status comprises one of:

the medical billing, diagnostic or procedural codes are accurate;

the medical billing, diagnostic or procedural codes are inaccurate;

or

the accuracy of the medical billing, diagnostic or procedural codes cannot be readily determined.

17. The method of claim 1, further comprising determining the medical billing, diagnostic or procedural codes meet or exceed a predefined threshold for having a high probability of being legitimate and not securely transmitting the text message in order to increase responsiveness of the medical consumer to a future text message for medical billing, diagnostic or procedural codes not meeting or exceeding the predefined threshold and therefore having a lower probability of being legitimate and thereby improving functioning of the cloud-based fraud prevention server by reducing processor and memory resources required for securely transmitting text messages.