Medical Billing & Healthcare
Health care carriers around the world are faced with medical billing fraud and inappropriate billing. With RiskShield for Medical Billing and Healthcare, INFORM offers a fraud prevention and risk assessment solution, especially for insurances (workers compensation, auto, general health insurers).
The aim is to present sophisticated claims investigators with a reduced number of highly suspicious claims for manual review. The incoming medical billing claims are analyzed to automatically extract claims that represent a potentially fraudulent activity or improper medical coding. RiskShield assesses any fraud risk of individual incoming medical billing claims in real-time in a matter of milliseconds and works transparently in the background.
Furthermore, RiskShield scores medical providers so that special attention can be given depending on their ranking.
- Real-time and high-performance detection engine
- Combination of all information available from different bills within one claim
- Pre-implemented fraud patterns such as up-coding, billing for services not rendered, duplicate charges, unbundling, and DME abuse
- Alignment of diagnosis codes with treatments
- Powerful case management tool providing a sophisticated view on case, bills and providers
- Achieving better fraud detection rates
- Detect impropper billing that can directly by denied to save unnecessary payouts
- Predictive analytics and Machine Learning
- Full transparency and traceability
- Uncover new fraudulent patterns
- Proven and reliable technology