Healthcare Fraud

A Miami physician is caught billing Medicare for $10 million in unnecessary HIV treatments. A five-state crime ring attempts to bilk Medicare of $100 million. And members of a Russian-American organized crime ring commit a $20 million fraud through a group of Los Angeles medical clinics. The FBI says that fraud cases like these—and thousands more of them— account for 3 to 10 percent of U.S. annual public and private healthcare spending. That equates to $75 to $250 billion in aggregate fraud losses every year.

More, larger healthcare fraud cases make the news every day, making it painfully clear that current fraud detection solutions aren't working. Current solutions consist of old, legacy systems that are not keeping pace with increasingly sophisticated techniques, and creative fraudsters continue to outsmart them with a breathtaking array of schemes. Claims payers, public and private, need a new approach — one that's more flexible, accurate, powerful, and proactive.

A Next-Generation Solution for Fighting Fraud

At Memento, we leverage our proven expertise fighting financial services fraud to help you combat the most complex, costly, and difficult-to-detect forms of healthcare fraud. Our next-generation Healthcare Fraud Solution helps you move from a reactive "pay-and-chase" model to a proactive "detect-and-deter" approach. Now you can identify fraudulent claims, scams, and organized criminal activity earlier—before big fraud losses happen.

We bring our sophisticated data management technology, advanced analytics, and integrated case management to bear on your claims, billings, and reference data, enabling prospective (pre-payment) and retrospective (post-payment) analysis. Memento's Healthcare Fraud Solution helps you:

  • Detect collusive networks of organized crime—Zero in on patterns of collusive activity and see links between fraudsters—including doctors, pharmacies, facility managers, and members. Get accurate alerts of suspicious activity that let your fraud prevention team and SIU take action proactively.
  • Spot fraud precisely—Our targeted, advanced analytical techniques and algorithms are designed to spot criminal activity hidden within your diverse data. Root out perpetrators and stop paying fraudulent claims. Leverage the power of our constraint-based sequence analysis, cluster detection, peer group profiling, and other wide-ranging analytical techniques designed to find more fraud with fewer false positives.
  • Manage cases more efficiently—Memento Case Manager provides a single, integrated system for case management and forensic investigations and audit. It automates your workflow, from alert aggregation and disposition to report form generation and regulatory filing support. Sophisticated collusive network visualizations help your investigators identify suspicious connections and stop high-loss collusive fraud.

A Complete Healthcare Fraud Solution—At a Fixed Price

Memento helps you implement and maintain a world-class fraud management platform—all for a fixed annual cost. Our Managed Services approach brings you the advanced capabilities of the Memento Healthcare Fraud Solution, in one comprehensive package that includes implementation, consulting services, training, and dedicated support. Tap our pre-built anti-fraud modules for pharmacy fraud, facility fraud, physician fraud, employee fraud, and more. Plus, our team of healthcare fraud experts and technologists continually enhances and optimizes our solution to ensure Memento's customers stay ahead of the dynamic nature of healthcare fraud.