Patent ID: 7873528

Claim:
A method of controlling healthcare claim payment losses, the method comprising: receiving from a payer a healthcare claim for services rendered to a patient by a provider, wherein a payer has screened the healthcare claim to confirm eligibility and further screened the healthcare claim to confirm compensability and wherein the payer has further determined that any related deductibles have been satisfied such that the payer is prepared to pay the healthcare claim, but prior to payment of the healthcare claim; evaluating the information for potential fraudulent activity associated with the healthcare claim wherein evaluating the information for potential fraudulent activity comprises running a plurality of rules, wherein the rules comprise: a first rule executing in one or more computer processors that accesses a database of provider information to determine whether the provider is licensed to provide the services set forth in the healthcare claim; a second rule executing in one or more computer processors that determines whether the distance between a patient's location as set forth in the healthcare claim and a provider's location as set forth in the healthcare claim exceeds a threshold, wherein the threshold varies based on whether the patient's home address is a rural location or an urban location and wherein the second rule is performed without reference to other healthcare claims associated with the provider and without reference to other healthcare claims associated with the patient; a third rule executing in one or more computer processors that compares billings as set forth in the healthcare claim to a patient's length of stay at a service facility as set forth in the healthcare claim, wherein the third rule is performed without reference to other healthcare claims associated with the provider and without reference to other healthcare claims associated with the patient; and a fourth rule executing in one or more computer processors that determines whether the services set forth in the healthcare claim are for single service billings and wherein the fourth rule accesses a frequency history of past services rendered to the patient to determine whether the single service billings have occurred multiple times; a fifth rule executing in one or more computer processors that determines whether the services provided to the patient as set forth in the healthcare claim are appropriate for the age of the patient; providing notification of potential fraud based at least partially on whether the plurality of rules indicate potential fraudulent activity, prior to the payer paying the healthcare claim.