Patent ID: 6826536
Filing Date: 2004-11-30
Classification: G06Q,G16H

Abstract:
A data processing system for detecting health care provider fraud, comprising:a. computer processor means for processing data; b. computer storage means for storing data on a storage medium; c. first means for initializing the storage medium; d. second means for processing data regarding payment claims submitted by health care providers to payers wherein said payment claim data is processed to identify and flag fraud-suspect inconsistencies and anomalies regarding payments claims submitted for payment by health care providers; e. third means for calibrating the processed data to enable appropriate identification of the fraud suspect inconsistencies and anomalies; f. fourth means for fraud-profiling of individual health providers based on an accumulated history of claims submitted by an individual health care provider; said data comprising an accumulated individual provider claim history of the individual health care provider; said fourth means further comprises means for inputting, displaying, retrieving processing, comparing, filtering and storing on the storage medium i. data comprising an accumulated history of discrete data representing claims submitted for payment by an individual health care provider being profiled; and ii. subjecting said data comprising said accumulated individual provider claim history to at least one profiling modifier fraud-flag data processing filter, said profiling filter identifying and fraud-flagging inconsistencies between said accumulated claim submission history of said individual provider when those data are compared to the normative health care parameters for the same medical care events and procedures derived from statistical normative data furnished by health care industry, insurance industry, and/or governmental health care insurance payer information data bases.