Health plan investigators rely heavily on tips from members, but those tips require a barrage of analytics and techniques performed by subject matter experts with clinical knowledge to verify them. While anomalies happen, it’s important to back up findings with evidence, or to find a larger pattern that could provide clues about intent.
Let’s look at a recent case where a Cotiviti client got a tip that resulted in the identification of more than $1 million in improper claims.
