However, despite the similarity of mechanisms between fraud and mimicry as evolutionary phenomena in nature, their goals are different. The evolutionary goal of mimicry is to maintain the accuracy of imitation for the longest possible time. The goal of fraud is to achieve the highest possible quick income, as over time, fraud detection methods improve, and the risk of discovering unacceptable behavior and corresponding penalties increases.
Detecting fraud statistically relies on at least two key factors:
- a large number of bills, which enables the recognition of diverse trends in how different clinics offer medical services;
- the extent to which the costs of services exceed reasonable limits, which provides a financial incentive for fraudulent actions.
Periodic alignment of mutual document workflow practices between the insurance company and the HCPs to minimize technical errors that may create opportunities for "disguising" fraud
Pre-approval of services by the insurance company
Data analysis and application of machine learning to identify anomalous and suspicious patterns
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Regular collection of feedback from the insured about types, quantities, and dates of services rendered
Auditing (internal and external): regular selective and comprehensive expert medical checks to confirm or alter the level of trust in the administration of the HCPs
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There are several main ways to combat fraud:
Main methods of combating the fraud