Insurance companies around the world today face the problem of how to deal with insurance fraud appropriately - in particular medical billing fraud. The aim is to present sophisticated claims investigators with a reduced number of highly suspicious claims for manual review. The incoming medical billing claims are analyzed to automatically extract claims that represent potential fraudulent activity or improper medical coding.
RiskShield assesses any fraud risk of individual incoming medical billing claims in real-time in matter of milliseconds and works transparently in the background. Upon receipt of a medical billing claim, the claims management system forwards it to RiskShield. The system uses rule sets and dynamic intelligent profiling to detect fraud patterns. Furthermore, RiskShield scores the medical providers based on the number of suspicious claims in which they are involved so that special attention can be given depending on their ranking.