Fraud Detection

Working in conjunction with your investigative team, United Review Services can assist with the medical provider fraud detection effort. We can work with SIU units, regulatory and licensing bodies and claims departments to help target potentially fraudulent billing.

With our core expertise in utilization review and medical bill auditing, we are able to review claim data and apply sampling methods to identify questionable billing or utilization trends. Based on what is identified, our client can proceed with investigation or negotiation activities, or utilize our Forensic Auditing capabilities.

Trends Identified:

• Excessive billing or treatment
• Medical coding maximization
• Inappropriate diagnostic codes
• Causality Issues
• Billing above R&C
• Multiple modalities and testing on every visit
• Lack of medical documentation
• Repetitive "boilerplate" medical reports
• Billing out of specialty

We partner with specialists who can analyze claim data and locate potentially problematic billing on a large scale basis, and also conduct our own reviews on randomly selected claim files. As part of the identification of potentially excessive or fraudulent provider billing, our Auditing R.N.s utilize their clinical experience and widely accepted resources in analyzing specific billing trends with certain providers. We can also conduct audits at the provider's location, where we can evaluate the clinical setting to determine whether the billed treatment was actually rendered and whether the office or clinic is qualified and has the actual staff and equipment to render the treatment.