We prospectively and retrospectively generate fully developed fraud and abuse referrals, investigate billings in order to obtain reliable evidence of fraud and abuse, and resolve issues through education, recovery and prevention strategies.

Medical Claims: We can respond to the latest schemes and generate fully developed leads for our investigative and resolution efforts. Approaches include:

• Prospective (prepayment) detection, investigation and resolution of suspected fraudulent/abusive claims. This helps address any immediate risk of overpayment while we work with the payer and providers to correct inappropriate billing practices.
• Retrospective (post-payment) detection, investigation and resolution of suspected fraudulent and abusive claims. These efforts identify and resolve through recovery, education and/or litigation such practices as claim misrepresentation, member sharing, kickbacks, routine waiver of co-insurance, and eligibility fraud.

Facility Claims: Using our detection software and investigative procedures, we examine DRG and other data such as related professional and ancillary claims, and determine, prospectively and retrospectively, which hospital claims exceed internal and industry benchmarks relative to length of stay and other criteria.

Pharmacy Claims: Our detection software evaluates pharmacy data and related medical data (if available) to identify potential issues such as services not rendered, doctor shopping, pharmacy shopping, return to stock, geographic inconsistencies, and prescription without expected medical services. This covers potential issues with the insured, pharmacies, pharmacists and prescribers, and supports referral, recovery and educational efforts performed by TriZetto, the client and/or the pharmacy benefit management (PBM) organization.

Benefits

• Generates fully developed fraud and abuse referrals
• Investigates billings in order to obtain reliable evidence of fraud and abuse
• Resolves issues through education, recovery and prevention strategies

Information

For more detailed information, please call 1-800-569-1222 or click on the link below. Request more information     Contact a sales rep