Healthcare claims loss control systems and methods

Abstract

A method for controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, evaluating the information including at least one of determining indications of fraud, validating service coding and editing as indicated, identifying possible payment discounts, and developing analytics indicative of risk for future claims, and providing loss control recommendations based at least partially on the evaluation, prior to paying the claim. Also a loss control system for healthcare claims with a loss control engine and a database in communication with the loss control engine, wherein the loss control engine accesses information about healthcare claims from the database after the claims have been processed for payment and wherein the loss control engine further analyses the claims for potential cost savings and returns a loss control recommendation for each claim to the database before payment of the respective claim.

1 . A method of controlling healthcare claim payment losses, the method comprising:
 accessing information about a healthcare claim after a payer is prepared to pay the claim, but prior to payment of the claim;   evaluating the claim information, wherein the evaluating comprises at least one of determining indications of a fraudulent claim;
 validating service coding and editing the coding as indicated; 
 identifying possible claim payment discounts; and 
 developing analytics indicative of risk for future claims; and 
   providing loss control recommendations based at least partially on the evaluation, prior to the payer paying the claim.