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

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf