With the high volume of claims we process on a monthly basis, we understand the importance of proper, adequate, and safe procedures. A&I has several automated and human processes established to monitor for fraudulent, excessive, or erroneous billing.

Our program includes several safeguards and policies to prevent and protect from fraudulent practices.

Fraud Specialist
We have an in-house fraud specialist who researches and studies the latest insurance scams and steps that can be taken to protect our clients. Research is conducted on a monthly basis with systems being updated as necessary and reports and staff training conducted at least on a quarterly basis or as needed.

Claims System Editor
Our system causes any claim meeting specific detection criteria to be pended and handled manually by a claims processor. Our system has the capability to edit for many circumstances, including but not limited to:

• Duplicate charges
• Procedures performed on the wrong gender
• Procedures performed on someone the wrong age
• Billings over the usual and customary fees charged for that procedure in that geographic area
• Unbundling of procedures. This is multiple procedures performed at the same site of the body. For example, if someone is having surgery on their lungs and liver at the same time, the doctor should not bill as if two surgeries were performed
• Red flagged providers. Providers become red flagged when a claims processor notes inappropriate or excessive billing from that provider
• Billings from providers near the Mexico border. Historically, some “clinics” in Mexico used clinics in the United States for their billing.
• Other insurance coverage for the patient whether it is a worker’s comp/accident situation or the patient has other health insurance
  

Education & Training
A&I holds regularly scheduled training on how to detect fraud for our staff. In addition, the participants are often the best resource for determining if a claim is fraudulently sent by a provider or someone pretending to be a provider. We recommend regular articles on fraud be included in newsletters and alert announcements.

Provider Database Maintenance
Only our senior claims processors may add a provider to the claims database. In order to add a provider, the processor must confirm the credentials and tax identification number of a provider. The processor also investigates any claim in which the provider is located a great distance from the employee.

Internal Controls
We have established several safeguards against internal fraud. These include such things as:

• Background checks prior to hiring any employee including a check of a person’s criminal record, financial record, and education and employment history
• Eligibility and enrollment functions are also done separately from claims processing functions. Thus, an employee could not add participants and also process claims that would be payable to those participants.
• Our claims system also provides security by feature and not just level of user. No employee is given access to a feature that is not required to perform his or her duties.

If Fraud is Suspected
If fraud is suspected, all documentation will be gathered and the client and plan participant is notified. Then depending on the circumstances, the FBI, State Insurance Commissioner, and/or State Medical Board will be notified. Fraud is an intentional act but sometimes mistakes are made. We are very careful to resolve any issues that arise leaving no stone unturned.

For information regarding our system and data backup as well as disaster recovery procedures, please visit the Systems & Technology tab.