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 ISO 9001 : 2000 (Quality Assurance Certified)  ,   ISO 27001 : 2013  (Information Security Management System)  &   British Council Certified

Medical Claims Investigation

OVERVIEW

Medical claims are medical bills submitted to health insurance carriers and other insurance providers for services rendered to patients by providers of care. The medical claim insurance is one of the common policies worldwide and some people take it a step further to gain it through fake claims, to an individual or a group. Our team of investigators includes medicos, paramedics, legal advisors, panel of honorary medical experts & experts from insurance industry.

Our professional claims investigators possess decades of vast experience and have established a proven reputation in the insurance industry for exposing fraudulent applications of medical claims. Mediclaim frauds can be fabricated via fraudulent physician’s prescriptions, false documents, false bills, exaggerated claims etc following are few common frauds
















TEN COMMON HEALTH CARE PROVIDER FRAUD SCHEMES


>   Billing for services not rendered.

>  Billing for a non-covered service as a covered service.

>  Misrepresenting dates & locations of service.

>  Misrepresenting provider of service.

>  Waiving of deductibles and/or co-payments.

>  Incorrect reporting of diagnoses or procedures (includes unbundling).

>  Over utilization of services.

>  Corruption (Bribery).

>  False or unnecessary issuance of prescription drugs.


Why do we investigate insurance claims?


>   To control the claim ratio (ICR – Incurred Claim Ratio)

>   To understand the behavior of hospitals in Region

>   To identify the adverse claims behavior

>   To identify the nexus if any, between any hospital and agent / client or other intermediary

>   To confirm hospital eligibility as per the policy conditions

>   To control prolonged hospitalizations and over-billing / over stay

>   To identify good hospital who are willing to work on reasonable SOC under TPA network of hospitals

>   To synchronize and educate hospitals / patients to utilize the policy in proper manner

>   To find frauds and misrepresentations

>   To find pre-existing ailments, OPD converted into IPD

>   To find authenticity of claim submitted.

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