Pre-Payment Fraud Prevention System

Payment Protector™ powered by PreSPOT™ our pre-payment rules-based inference engine, and PrePATE™ our pre-payment predictive analytic technology engine, is an advanced fraud prevention system that works prior to the disbursement of funds.

Payment Protector acts as management’s command center for avoiding the payment of potentially fraudulent claims.The easy-to-use Graphical User Interface (GUI) is specifically designed for use by SIU staff to conduct pre-payment antifraud examinations of claims requested by provider relations, medical economics, finance and internal audit. The system works across all healthcare claim types including, medical, facility, pharmaceutical and dental.

Payment Protector is designed for maximum flexibility in configuration allowing for instant intervention. The system also allows each organization to utilize their established policies and procedures regarding adjudication and investigation. Claims data is collected daily and is strategically examined based upon SIU specified rules and schemes. Suspicious claims are flagged and sent to a built-in resolution system for further deliberation by investigators.

Resolution Workbench™ is a built-in automated payment decision tool. This robust tool allows investigators to swiftly release viable claims, resulting in faster prompt-pay compliant reimbursement for providers. For denied claims, Resolution Workbench assists the investigator in launching a full-scale, defendable investigation of the suspected live claims.

Payment Protector and Resolution Workbench work in conjunction with Intelligent Investigator™ our post-payment fraud detection system to seamlessly build a comprehensive database of offending providers. All programs are written in modern java and will instantly run on any networked PC, or are available as a SaaS (Software as a Service) fully hosted option.

The key benefits of Payment Protector include:

• Higher savings associated with not having to “pay and chase”
• Investigations are more effective and defendable with rules that have been proven against billing patterns identified in your claims history
• Resolution Workbench™ makes investigators more efficient in examining claims with a drilldown tool that helps automate their resolution
• Providers are more responsive to requests for additional information prior to payment
• Mitigation of potential patient safety issues, a concept that encompasses medical necessity