Patent application number | Description | Published |
20130006655 | NEAR REAL-TIME HEALTHCARE FRAUD DETECTION - A healthcare fraud management system is configured to store multiple rules for detecting healthcare fraud, receive a healthcare claim involving a provider and a beneficiary, and obtain other healthcare fraud information associated with the provider or the beneficiary. The healthcare fraud management system is further configured to select rules, from the multiple rules, based on information associated with the claim, information associated with the provider or the beneficiary, and the other healthcare fraud information. The healthcare fraud management system is also configured to process the healthcare claim using the selected rules to generate a fraud score, and output, prior to payment of the healthcare claim, information regarding the fraud score to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claim. | 01-03-2013 |
20130006656 | CASE MANAGEMENT OF HEALTHCARE FRAUD DETECTION INFORMATION - A healthcare fraud management system receives healthcare claims associated with a particular entity, selects rules, from a plurality of rules for detecting healthcare fraud, based on information associated with the healthcare claims, and processes the healthcare claims using the selected rules to generate alarms. The healthcare fraud management system prioritizes, based on the generated alarms, healthcare information associated with the particular entity in relation to healthcare information associated with other entities. The healthcare fraud management system provides for display, prior to payment of the healthcare claims, the prioritized healthcare information associated with the particular entity and the other entities. | 01-03-2013 |
20130006657 | REPORTING AND ANALYTICS FOR HEALTHCARE FRAUD DETECTION INFORMATION - A healthcare fraud management system receives healthcare claims information associated with a particular entity, and receives historical healthcare information associated with the particular entity. The healthcare fraud management system also performs data mining techniques on the historical healthcare information to produce data mining information associated with the particular entity. The healthcare fraud management system generates reports, associated with the particular entity, based on the healthcare claims information, the historical healthcare information, and the data mining information, and outputs the generated reports to a clearinghouse or a claims processor. | 01-03-2013 |
20130006668 | PREDICTIVE MODELING PROCESSES FOR HEALTHCARE FRAUD DETECTION - A healthcare fraud management system receives healthcare claims, performs data reduction on information associated with the healthcare claims, and processes the reduced information associated with the healthcare claims by using a plurality of rules. The system also generates alarms, for the healthcare claims, based on the processing of the reduced information associated with the healthcare claims, generates scores for the alarms based on one or more predictive modeling rules, and prioritizes the healthcare claims, to create a list of prioritized healthcare claims, based on the generated scores for the alarms corresponding to the healthcare claims. The system further outputs, prior to payment of the healthcare claims, the list of the prioritized healthcare claims to a clearinghouse or a claims processor to assist the clearinghouse or the claims processor in determining whether to accept, deny, or review the healthcare claims. | 01-03-2013 |
Patent application number | Description | Published |
20100080372 | METHOD AND APPARATUS FOR PROVIDING FRAUD DETECTION USING HOT OR COLD ORIGINATING ATTRIBUTES - An approach provides fraud detection in support of data communication services. A list of single-event attributes (e.g., hot or cold attributes) is generated and includes a network address of an end user host originating a data call or a calling party identification (e.g., Automatic Number Identification (ANI) or an originating Calling Line Identification (CLI)) for network access, wherein entries of the list specify values of the hot attributes. An attribute value associated with the data call is compared with the entries. A fraud alert is generated if the attribute value matches one of the entries. | 04-01-2010 |
20110107421 | METHOD AND APPARATUS FOR PROVIDING FRAUD DETECTION USING CONNECTION FREQUENCY THRESHOLDS - An approach provides detection of unauthorized use of data services. A determination is made as to whether connections supporting remote access to a data network are completed. The number of completed connections associated with a selected attribute is tracked over a time period. It is then determined whether the number of completed connections satisfies a connection frequency threshold. A fraud alert is generated if the connection frequency threshold is satisfied. | 05-05-2011 |
20120158540 | FLAGGING SUSPECT TRANSACTIONS BASED ON SELECTIVE APPLICATION AND ANALYSIS OF RULES - A fraud management system is configured to store rules for detecting fraud. The fraud management system is configured to: receive a transaction involving a consumer and a merchant; select a set of the rules based on information associated with the transaction, information associated with the consumer, or information associated with the merchant; process the transaction, in parallel, using the selected rules to generate a set of alarms; group the alarms, into groups, based on information associated with the transaction; analyze the groups to generate a fraud score; and output information regarding the fraud score to the merchant to notify the merchant whether the transaction is potentially fraudulent. | 06-21-2012 |
20120158541 | USING NETWORK SECURITY INFORMATION TO DETECTION TRANSACTION FRAUD - A fraud management system is configured to store rules for detecting fraud. The fraud management system is further configured to receive a transaction involving a consumer and a merchant; obtain network security information associated with malicious activity in a voice network or a data network, where the network security information indicates that the consumer has been involved in malicious activity in the voice network or in the data network; select a subset of rules based on the network security information and information associated with the transaction, the merchant, or the consumer; process the transaction using the subset of rules to generate alarms; process the alarms to generate a fraud score for the transaction; and output information regarding the fraud score to the merchant to assist the merchant in determining whether to accept, deny, or fulfill the transaction. | 06-21-2012 |
20120158586 | AGGREGATING TRANSACTION INFORMATION TO DETECT FRAUD - A fraud management system is configured to receive a transaction from a merchant; select rules to use to process the transaction; process the transaction using the selected rules to generate a set of alarms; and generate an alarm score for each of the alarms. The fraud management system is further configured to combine the alarms with alarms from one or more other transactions to form a combined set of alarms; sorting alarms, in the combined set of alarms, into groups based on attributes of the transaction; generate a group score, for each group, based on at least one of the alarm scores for at least one alarm in the group; generate a fraud score, for the transaction, based on one or more of the group scores; and output information regarding the fraud score to the merchant to notify the merchant whether the transaction is potentially fraudulent. | 06-21-2012 |