Combatting Healthcare Fraud and Waste
Protect your business from rising healthcare costs and financial losses. Discover how Total Employee Sourcing LLC helps you identify and prevent healthcare fraud and waste.
Understanding healthcare fraud and waste
Healthcare fraud and waste improperly or unnecessarily use healthcare resources. Both drive up costs and impact your business's bottom line.
What is fraud?
Fraud is intentional deception, such as billing for services never provided or submitting false information to get paid. This directly leads to higher premiums and financial losses for businesses.
What is waste?
Waste is unnecessary or inefficient spending, like ordering duplicate tests or providing non-medically necessary services, even without intent to deceive. This also makes healthcare more expensive for employers.
Why it matters to your business
Healthcare fraud and waste lead to increased premiums, lost money, legal penalties, regulatory problems, and damage to your company’s reputation. Protect your assets with our expert solutions.
Our proactive approach to prevention
At Total Employee Sourcing LLC, we prioritize preventing fraud and waste before it impacts your business. Our strategies focus on early detection and data-driven analysis to safeguard your healthcare spending.
Specialized services for fraud detection
Total Employee Sourcing LLC uses advanced techniques to identify and prevent healthcare fraud, waste, and abuse:
- Claims-data analytics: We analyze 100% of claims to spot unusual billing patterns, duplicate claims, excessive utilization, upcoding, and other anomalies, identifying statistical outliers and rule violations.
- Pre-payment review: Our systems flag suspicious or medically unnecessary claims before they are paid, combining AI, machine learning, rules, and clinical review for proactive prevention.
- Provider screening and profiling: We check providers against sanction/exclusion lists and compare their billing and utilization patterns with similar providers to identify outliers.
- Medical and coding audits: We conduct thorough reviews of claims and medical records to ensure accuracy and compliance.
Why our approach is superior
Our approach stands out because we focus on proactive prevention rather than the traditional "pay and chase" model. We combine:
- Early detection: Identifying suspicious claims, providers, and billing patterns before they lead to expensive losses.
- Data-driven analysis: Utilizing claims data, statistical analysis, and AI to uncover patterns that manual reviews might miss.
- Human expertise: Experienced reviewers investigate flagged claims, ensuring accuracy and avoiding false positives.
- Focus on both fraud and waste: We look beyond intentional fraud to address unnecessary services, duplicate payments, and inefficient care.
