Systems and methods for reducing medical claims fraud
First Claim
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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.
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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.
46 Citations
17 Claims
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1. A method comprising:
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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. - View Dependent Claims (2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17)
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Specification