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Process Group

Audit/Fraud Mangement

Objective

Identify cases of unusual patterns of insurance use that demonstrate suspicious utilization of program benefits by providers and beneficiaries

Input

  • Provider identifier

  • Beneficiary identifier

  • Benefit plan

  • Claims identifier

  • Provider accumulators

  • Beneficiary accumulators

  • Medical history

  • Provider performance

  • Beneficiary benefits utilization

Output

  • List of suspected cases

  • Fraud case identifier

  • Case inquiry

Measurable Outcomes

  • List of suspected cases

  • Case status

  • Percentage of fraudulent claims

  • No labels
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