Cost of Fraud, Abuse, and Waste in Healthcare is a colossal problem resulting in billions of dollars. For government health programs this obviously results in a huge impact to the American tax payers.

Healthcare fraud – especially Medicare and Medicaid fraud – occur in many ways for personal gain of individuals, whether providers or, in some cases care-givers. These can typically be classified as one or the following:

• Billing Fraud
• Falsification of patient diagnosis
• Unbundling of procedures
• Kickback fraud

In most cases, payer agencies are wrongly billed for services that were never rendered (to genuine or stolen identity patients) or by falsely including tests and exams to justify surgeries, treatments, procedures, or drug regiments. Home-based patient care is also at times a part of the scenario.

CNSI solutions for fraud and abuse prevention help agencies manage claim adjudication efficiencies to reduce and recover costs and wasteful spending - whether proactively by flagging patterns based on probability to suspend payment before it is made, or detecting errors after payment to help identify what needs to be recovered and from who.