Although isolated errors are consistently made in claims submission, tools which can help see beyond them and isolate patterns that are suspicious for fraud on a grand scale, or at least waste or abuse of a significant scope, can prove valuable.

Overutilization in Healthcare is a problem which has been estimated to cost in the range of hundreds of billions of US dollars every year. Despite historically spending more than double per person on healthcare than the average developed country, our outcomes have not been significantly better.

Telemedicine has grown significantly in recent years due to new technologies and consumer demand. Payer reimbursement policies, on the other hand, are slow to adapt to the new services.

It’s been called the most sinister, the most egregious, the worst kind of health care fraud – providers performing medically unnecessary procedures. When this type of fraud makes the headlines, it is indeed sensational.

Before the use of electronic claim submissions and EHRs, the only option payers had to detect fraud, waste and abuse was “foot-on-the-ground” auditing at provider sites. Even today many payers still rely on this manual process. These types of audits are time consuming, expensive and performed after claims have already been paid. Technological advances have radically changed FWA pattern recognition. Today, statistical sampling based physical claim audits aren’t necessary when payers can automate testing 100% of claims.