Fraud detection and prevention in the US through real-time point-of-care circuit and healthcare analytics

In our over 20 years of experience serving health insurance and workers’ compensation clients in the United States and around the globe, Conexia has achieved a deep understanding of the different types of fraud in this space. Using this experience, Conexia has designed platforms that help to detect and prevent certain types of fraud, saving money for our clients.

A common type of fraud amongst medical and ancillary service providers involves kickback schemes to generate billings for unnecessary referrals and treatments. In these cases, the implementation of the real-time, point-of-care circuit within the workers’ compensation ecosystem supports regulators, providers, employers, and injured workers’ interests by reducing costs while improving care delivery and outcomes.

The United States is not immune to these issues. The Department of Justice has taken historic new steps to go after fraudsters, including hiring more prosecutors and leveraging the power of data analytics. (1)

Conexia’s expertise with a large client illustrates the impact of detecting and stopping fraud using healthcare analytics. Working together with the client, we detected fraud in two instances, one related to an inflated number of providers’ daily transactions and another by manual entry of false identity beneficiary data.
Through the generation of proposals to alert about fraud with real-time circuit solutions and healthcare analytics, Conexia introduced controls that resulted in over $1 million dollars in annual savings.

 

(1) According to Department of Justice U.S. Attorney’s Office, District of Nevada, June 28, 2018: https://www.justice.gov/opa/pr/national-health-care-fraud-takedown-results-charges-against-601-individuals-responsible-over

 

Discover one of our Healthcare Analytics Success Story:

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