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JLN Process - Identify fraudulent cases

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Created by tabea.boateng, last modified on Feb 17, 2020

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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

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