Fraud and Abuse
The landscape of health care fraud changes from year to year, region to region, provider to provider. Health care fraud schemes, as creative as the perpetrators who concoct them, cannot be investigated in a "one size fits all" fashion. Conditional fraud requires painstaking case analysis and the implementation of individualized strategies. Limited personnel, rigid auditing systems, lack of specific expertise (eg CPT®, ICD-9, HCPCS), and time constraints can impede even the most proficient of investigators in pursuit of their organizational objectives.
Pyramed is well versed in the complexities and characteristics of healthcare fraud investigations. We understand the pervasiveness of healthcare fraud. Armed with boundless skills and industry knowledge we work in tandem with investigative professionals in the fight against healthcare fraud. We can analyze your case, identify your needs and respond with strategies designed to put you on a path towards a successful case outcome.
Our sophisticated technology allows us to profile the information in all your health care claims for the purpose of establishing norms of activity, utilization and performance. Patients, providers, diseases, procedures and other factors can be profiled, analyzed and examined, trends can be identified and comparisons can be made.
- Provider and staffing profiles
- Deception detection
- Data development and analytics
- Aberrant behavior patterns
- Trends recognition (Data driven and/or manual assessment)
- Outlier detection
- Regulatory Compliance
- Utilization review (Integrity of claims)
- Statistical sampling and accuracy errors
- Project management and case preparation
- Expert Testimony
Personal Injury / Casualty Medical Claims Evaluation
Studies have shown that about one-third of all medical losses claimed in auto accidents were unnecessary or exaggerated. According to the Insurance Research Council: The property-casualty insurance industry is likely to become the target of significant additional cost-shifting by hospitals, physicians, and other medical providers responding to the cost-containment provisions of the Patient Protection and Affordable Care Act (ACA). The ACA dramatically alters healthcare markets and health insurance systems in the United States. Although the property-casualty insurance industry is not directly included or targeted by the act, it is not entirely immune to its effects. As a purchaser of healthcare services and as a participant in healthcare markets, the property-casualty industry finds itself in a changed environment, where the medical providers with whom they engage and the claimants they serve are themselves confronted by major changes related to the ACA. Increased cost-shifting could have potentially significant and long-lasting consequences for property-casualty insurance. Cost-containment efforts by other public and private health insurance systems are likely to result in higher billings and higher utilization when property-casualty insurance claims are involved in the months and years ahead, as medical providers seek to offset lost revenue from health insurance sources.
According to the NICB
According to NICB, because property-casualty insurance is not covered by the ACA, career criminals and unscrupulous medical providers will shift their attention to the property-casualty business to avoid increased scrutiny from health insurers.
Reviewing charges for reasonableness is a check and balance on the billing process, to make sure claimed charges are not too high, and that charges are for services that were rendered and appropriately billed. Pyramed provides a customizable audit platform to assess the proper and reasonable medical damages associated with treatment of an injury enabling claims professionals to make informed decisions around medical bills related to liability claims. Assisted by our sophisticated technology, disciplined approach, and technically competent staff, and with the highest level of confidentiality, Pyramed offers impartial reviews for successful resolution of healthcare billing disputes and investigations.
- Complex damages evaluation including review of coding (CPT, ICD-9, HCPCS, DRG), identification of duplicate, invalid, upcoded, unbundled and/or unreasonable charges
- Usual and customary review
- Provider and staffing profiles
- Deception detection
- Data development and analytics
- Aberrant behavior patterns
- Regulatory Compliance
- Utilization review (Integrity of claims)
- Case preparation assistance
- Expert Testimony