| 摘要 |
A method of controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, applying at least one rule to the information, wherein the at least one rule is adapted to determine indications of fraud and if fraud is indicated, flagging the claim, else recommending payment, wherein flagging of the claim or recommending payment occurs prior to payment. Also, a healthcare claim loss control system including a database having data related to healthcare claims and a loss control engine in communication with the database wherein the loss control engine accesses data corresponding to a healthcare claim when the claim is ready for payment, but before payment of the claim occurs and wherein the claim scoring engine applies at least one rule adapted to identify fraud and flags the claim for any indicated fraud before payment of the claim.
|
