Systems and Methods for Reducing Medical Claims Fraud

• US 20130124223A1
• Filed: 11/14/2011
• Published: 05/16/2013
• 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.
• Granted Patent: US 9,727,919 B2
• Time in Patent Office: Days
• US Class Current: 705/3
• 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 for reducing fraudulent use of a medical identity to obtain medical goods or services, comprising:

receiving identification information for a medical insurance account of a medical consumer;

receiving medical claims data associated with the medical insurance account;

transmitting the medical claims data to the medical consumer; and

receiving a confirmation status from the medical consumer for the medical claims data.

2. The method of claim 1, wherein the medical insurance account identification information 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 claims data comprises 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 claims data to the medical consumer comprises alerting the medical consumer that medical claims data have been received.

5. The method of claim 1, further comprising securely transmitting the medical claims data to the medical consumer.

6. The method of claim 1, wherein transmitting medical claims data to the medical consumer comprises sending an electronic mail message, a text message, a message delivered via a social media web site, a telephone call, or a letter to the to the medical consumer.

7. 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 claims data are accurate;

confirmation from the medical consumer that the medical claims data are inaccurate;

or

notification that the medical consumer is unable to determine the accuracy of the medical claims data.

8. The method of claim 7, further comprising initiating further communications with the medical consumer when the medical consumer confirms that the medical claims data are inaccurate or is unable to determine the accuracy of the medical claims data.

9. The method of claim 7, further comprising notifying a provider of the medical insurance account when the medical consumer confirms that the medical claims data are inaccurate or is unable to determine the accuracy of the medical claims data.

10. The method of claim 1, wherein receiving confirmation status from the medical consumer comprises receiving notification that the medical consumer has viewed the medical claims data.

11. 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 claims data.

12. The method of claim 1, further comprising notifying a provider of the medical insurance account after a determination has been made that the medical claims may be fraudulent.

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

14. The method of claim 1, further comprising:

receiving an enrollment request from the medical consumer for a medical fraud alert service;

authenticating the identity of the medical consumer by providing to 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; and

receiving a response from the medical consumer indicating which of the plurality of medical goods or services are actual goods or service and which are fictitious goods or services.

15. 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.

16. The method of claim 1, further comprising transmitting a reminder to the medical consumer when the medical consumer fails to confirm the status of the medical claims data after a predetermined period of time

17. A method for reducing fraudulent use of a medical identity to obtain medical goods or services, comprising:

receiving identification information for a medical insurance account of a medical consumer;

receiving medical claims data associated with the medical insurance account;

applying analytics to the medical claims data;

requesting verification of the medical claims data from the medical consumer when the analytics indicate an abnormality; and

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

18. The method of claim 17, wherein receiving a response to the verification request from the medical consumer comprises receiving one of:

confirmation from the medical consumer that the medical claims data are accurate;

confirmation from the medical consumer that the medical claims data are inaccurate;

or

notification that the medical consumer is unable to determine the accuracy of the medical claims data.

19. The method of claim 18, further comprising initiating further communications with the medical consumer when the medical consumer responds that the medical claims data are inaccurate or is unable to determine the accuracy of the medical claims data.

20. A method for reducing fraudulent use of a medical identity to obtain medical goods or services, comprising:

receiving medical claims data associated with a provider of medical goods or services, the medical claims data comprising medical claims made to a provider of medical insurance;

applying analytics to the medical claims data; and

notifying the provider of medical insurance when the analytics indicate an abnormality.

21. The method of claim 20, further comprising:

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

requesting confirmation of the medical claims data from the medical consumer; and

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

22. A method for reducing fraudulent use of a medical identity to obtain medical goods or services, comprising:

developing a database of medical insurance account information for a plurality of medical consumers, the database comprising a fraud alert status of each medical insurance account;

receiving a request from a provider of medical goods or services for the fraud alert status of the medical insurance account of a medical consumer; and

sending enhanced medical consumer identification information to the provider of the medical goods or services when a fraud alert has been associated with the medical insurance account.

23. The method of claim 22, wherein the enhanced medical consumer identification information comprises biometric data.

24. The method of claim 22, wherein the enhanced medical consumer identification information comprises a photographic image of the medical consumer.

25. The method of claim 22, wherein the enhanced medical consumer identification information comprises unique indentifying information associated with the medical consumer.

26. A system for reducing fraudulent use of a medical identity to obtain medical goods or services, comprising:

a central processing unit (CPU) operatively connected to memory; and

code stored by the memory causing the CPU to perform the following steps;

receive identification information for a medical insurance account of a medical consumer;

receive medical claims data associated with the medical insurance account;

transmit the medical claims data to the medical consumer;

receive a confirmation status from the medical consumer for the medical claims data; and

transmit the confirmation status to a provider of the medical insurance account.

27. The system of claim 26, wherein the confirmation status comprises one of:

the medical claims data are accurate;

the medical claims data are inaccurate;

or

the accuracy of the medical claims data cannot be readily determined.

28. The method of claim 26, wherein the code further causes the CPU to initiate further communications with the medical consumer when the confirmation status is either the medical claims data are inaccurate or the accuracy of the medical claims data cannot be readily determined.

29. A non-transitory computer readable storage medium having embodied thereon a program, the program being executed by a processor to perform a method for reducing fraudulent use of a medical identity to obtain medical goods or services, the method comprising:

receiving identification information for a medical insurance account of a medical consumer;

receiving medical claims data associated with the medical insurance account;

transmitting the medical claims data to the medical consumer;

receiving a confirmation status from the medical consumer for the medical claims data; and

transmitting the confirmation status to a provider of the medical insurance account.

30. The computer readable storage medium of claim 29, wherein receiving confirmation status from the medical consumer comprises receiving one of:

confirmation from the medical consumer that the medical claims data are accurate;

confirmation from the medical consumer that the medical claims data are inaccurate;

or

notification that the medical consumer is unable to determine the accuracy of the medical claims data.

31. The computer readable storage medium of claim 30, further comprising initiating further communications with the medical consumer when the medical consumer confirms that the medical claims data are inaccurate or is unable to determine the accuracy of the medical claims data.

32. The computer readable storage medium of claim 30, further comprising notifying a provider of the medical insurance account when the medical consumer confirms that the medical claims data are inaccurate or is unable to determine the accuracy of the medical claims data.

33. The computer readable storage medium of claim 29, further comprising:

receiving an enrollment request from the medical consumer for a medical fraud alert service;

authenticating the identity of the medical consumer by providing to 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; and

receiving a response from the medical consumer indicating which of the plurality of medical goods or services are actual goods or service and which are fictitious goods or services.