Medical Billing & Healthcare

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Overview

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.

Key Features

  • 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

Key Benefits

  • 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

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