Detection identifies fraud, waste, and abuse or the potential for improper payments through continual analysis of data in order to discover and address issues. Detection unveils instances of payments that are inaccurate, using risk assessment as well as predictive analytics.

Dectection includes:

• Provider reviews to establish the validity of medical and prescription claims by such actions as contacting providers for verification or communicating with members to assure receipt of services or prescribed drugs.
• Provider credentialing to verify practitioner qualifications including certification, training, licensure and criteria related to professional conduct.
• Beneficiary reviews.
• Routine and random audits as part of a fraud, waste and abuse program including contractor performance, provider, pharmacy and member audits.
• Investigate compliance and identify discrepancies through examination of a sample or the universe of payment and utilization reports and other records by desk or on site audits.
• Data analysis to identify new forms of improper payments and ongoing monitoring of schemes.