Combat Fraud in Healthcare
A consumer, let’s call her Alyssa, is ready to purchase an item. At checkout she sees a familiar button. Alyssa had enrolled in this experience the last time she shopped online, so she decides to use it again.
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DEMO
Digital Shopping Application (DSA): Merchant, Marketplace, Hosted order page provider
Identifying the Button
SRC Roles and Participants
UI and experience shown are samples only and are subject to change.
Show phone
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02
New Account
Login (Desktop Biometrics)
Authenticate
Enroll fingerprint
Enroll FaceID
Enroll Voice Print
Upload ID
Risk Manager
Dashboard
© 2019
Reports
A customizable Dashboard delivers real-time updates on the topics of greatest interest to each user
The user wants to review alerts the Risk Manager has identified as potential fraud
User chooses to view all Providers
Case Manager
Providers
Claims
User can choose Claims or Providers from Risk Manager module
User chooses to view all Claims
In Providers view, AI models alert user to those needing review
View by:
View underlying data
Our AI solution continuously monitors provider behavior and risk levels across all vectors, channels, and transactions to help manage fraud risk in real-time
AI analyzes 24 months of data and identifies suspicious claims and automatically creates new models to enhance both pre- and post-payment
Users can view the underlying Data that determines the Score
Viewing providers with high potential for fraud, user decides to investigate provider Stanley Zbornak
Fraud score is automatically sorted by descending value
User views more Claim alerts for the selected Provider
Stanley Zbornak, MD
Claim alerts for:
Viewing more claims details, user can see all active alerts for this provider
User decides to investigate provider's patient with high fraud score
All Claims by Provider All Claims by Patient Alerts Paid Denied Pending
Radio buttons provide user several ways to view claims details to assist in making a determination
User views more Provider Claims for this patient
Patient 232T74789
Claims for:
With claims sorted by Rationale, the user can see that this provider has submitted several older claims for this patient with a similar rationale denied in the past
Provider:
User selects the Provider's claims for one of its patients
User views AI-derived alerts and supporting data to make decisions
After viewing details, the user is ready to make a final determination for the selected Provider
Back to Claims
User is ready to make a determination
User clicks on Provider Determination
User puts Provider on pre-payment Review based on their investigation
After reviewing all details for this provider alert, user determines that provider should be placed on pre-payment review
Review
Deny
Monitor
Validate
Pay
Submit
Notes: Selecting Review, as the rationale and supporting information appear to support the score/alerts. Provider has been observed to routinely bill unites higher than expected, has billed for more comprehensive/complex services than Dx's would appear to support, often at a frequency that is more than what might be reasonable. Requesting medical records to validate services billed.
Determination submitted.
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Please contact your Mastercard representative to learn more about how we can help you combat fraud in healthcare.
