Fraud & Abuse

Better to Stop, Than to Chase.

Identifying fraud, waste and abuse in healthcare is a crucial component in the overall strategy to reduce spiraling costs. While the vast majority of health insurance claims are made in good faith, a certain percentage qualify as fraud. In recent years, public and private insurers have invested millions of dollars to identify fraud.

Many fraud detection solutions use neural networking tools or rely on cross checking public databases for indicators of fraud after claims are paid. With ConVergence Point, payers have a new twist on the standard pay and chase fraud detection model. ConVergence Point stops miscoded claims from being paid while gathering claims data to identify variances and outliers against user-defined norms.

ConVergence Point Fraud and Abuse Highlights:

• Miscoded claims identified and stopped before entering the transaction system
• 80 terabyte data warehouse for trend analysis and variance reporting
• Very granular analytics can report aberrant behavior in terms of procedures, visit levels, place of service, units or any other pertinent data to pinpoint problems
• Adjunct to current fraud and abuse systems already in place