System and method for detecting healthcare insurance fraud

摘要

A system and method for detecting healthcare insurance fraud is disclosed. The method includes creating a database containing source data related to at least one healthcare claim submitted for reimbursement, selecting data from the database to compare to a set of rules using an audit module, and comparing the selected data to the set of rules using the audit module. The method also includes using the audit module to automatically identify suspected fraudulent data when the selected data violates at least one rule of the set of rules and using the audit module to flag the fraudulent data. In addition, the method includes using the audit module to generate a report illustrating patterns of irregularities within the source data to visually identify the fraudulent data displayed within the source data by user-friendly graphs and charts, and generating at least one automated statement for display to identify the at least one rule of the set of rules that was violated by the selected data using a documentation module.