Customer Benefits/ROI

FraudLens believes that the best way to stop

these losses is through

early detection and better provider management

FWA represents 10-14% of your total healthcare spend and in some cases may reach 25% for a total dollar amount of $750 billion per year.

ROI of Near Real-Time FWA Detection

The current “pay and chase” approach is inherently inefficient. Paying the providers and then chasing those providers years later is very expensive and at best will result in a recovery of pennies on the dollar many years after the fraud is committed. When you read about a provider who was convicted of $1 million in FWA via the "pay and chase" process, the amount of the $1 million that is actually recovered is likely no more than $100,000.

In contrast, FraudLens identifies the FWA early and permits the payer to intervene early when the FWA is still small amounts of money. Stop FWA payments at this stage and small problems never get a chance to grow into large problems. Because FraudLens identifies ALL the providers who are submitting FWA claims, early intervention prevents a large dollar loss (a small dollar loss per provider times a large number of providers equals a large dollar loss). Further, since the FWA claims are never paid, the payer saves the entire FWA amount over a large number of providers. FraudLens provides large savings that are dollar for dollar not pennies on the dollar.

With fully implemented FraudLens solution*, you could attain an ROI of 7 to 1 or more.

FraudLens Multi-Vectored Approach will tell you exactly who has committed FWA, what was fraudulent, when it happened, where it happened, and how it happened. The result is that FraudLens detects the maximum number of providers who are misusing the system with great precision.

The Loss of Small Dollar Amounts across many providers over time become Large Total Dollars Lost

The majority of dollars that are lost to FWA can be attributed to a large number of providers who are constantly defrauding payers of small amounts of money on a continuous basis. These providers are NOT hardened criminals but rather basically honest providers who are taking advantage of vulnerabilities in the system. The FraudLens solution solves this problem by detecting patterns that indicate potentially bad behavior across all providers. If these incidents are detected early, immediate action can be taken preventing this from happening again.

Recovery of Historical Fraud

The essence of FraudLens is to develop better provider management and push them to submit only legitimate claims, who continue to defraud the payers by ‘gaming the system’. This is the only way that will lead to significant reduction in FWA. FraudLens is a new and an additional way to deal with the problem of FWA. It is NOT meant to completely replace “Pay and Chase” because “Pay and Chase” still has value. Rather FraudLens is meant to work in parallel with and to supplement “Pay and Chase”. FraudLens, in its normal operations, identifies historical instances of FWA that may have been overlooked because of the demands and limitations of “pay and chase”. In such instances, FraudLens provides the detailed evidence of historical FWA that can be recovered by the “pay and chase” method.

When the bulk of your losses comes from a large number of basically honest providers who are constantly defrauding payers of small amounts of money on a continuous basis, it is counterproductive to use the threat of criminal prosecution as the initial step to stopping the fraud. Fraudlens believes that the best way to stop these losses is through better provider management. We achieve this by:

  • Real-time provider communication upon detection of a potentially fraudulent act
  • Provide these providers with sufficient evidence of their potential wrong doing.
  • Once an FWA act is confirmed, offer the bad acting provider an easy way out of trouble by addressing the issue and push them to submit only legitimate claims.
  • The tone of the provider communication starts as non-accusatory and escalates in stages until the final stage if necessary, which is referral for criminal prosecution.

The early stage provider communication is designed to address the remediation of honest errors (clerical, poorly trained staff). The middle stages seek to address the problem through retraining and re-education. The later stages are designed to alert the bad acting provider that FraudLens has exhausted honest remediation and that only a deliberate act of FWA can explain the ongoing resistance to change. The goal is to build a better and trusted bond with providers so they will only avoid submitting suspected and fraudulent claims.

FraudLens’ comprehensive and complement solution provides support for all different departments of your organization in many ways:

The FraudLens solution can be used effectively by novices. Almost every task or query in FraudLens can be performed with the click of your mouse.

All of the hard work is done in the background so the user does NOT have to interpret any results. The results are converted into colored circles that each represents a provider, while the color of the circle tells the user if there is FWA.

The three colors used for detection are those that every individual can clearly associate with other areas of their everyday lives. A green circle means that a provider is fine and no fraudulent activity has been detected. A yellow circle represents a provider whose actions are borderline and may need to be looked at further. Finally, a red-colored circle indicates that FraudLens has determined that this provider has committed a bad act and intervention is required immediately.