The Fraud & Abuse Prevention Suite is Comprised of Five Proven and Proprietary Services Which Combine to Detect and Report Healthcare Fraud Detection and Deliver Reductions in Total Claims Costs of Up to 6%

Provider Integrity Program
Prospective Tools for Validating the Integrity of Provider Claims

Fraudulent healthcare claims generate a large portion of more than $250 billion in healthcare overpayments. TC³ provides healthcare payers with a highly effective system for healthcare fraud detection . Claims that are questionable or fraudulent are flagged and reviewed prior to payment. The spiraling cost of healthcare claims is at an all time high making fraud detection mechanisms not only a desirable business asset, but also a necessity.

TC³’s Provider Integrity Program (“PIP”) is a comprehensive provider data analysis and modeling application designed to review healthcare claims that may represent questionable or abusive billing practices. Historically, PIP has provided savings in healthcare fraud detection in the range of 1% - 3% of total claims dollars which are in addition to any identified by internal systems or procedures.

To help detect healthcare fraud PIP examines and flags potential claims daily prior to payment. The review process identifies claims and providers processed by a payer’s system and compares each claim against proprietary databases that are updated daily from ongoing investigations. This prevents claims from being paid out in error and provides the claim file documentation for the payment avoidance or the reduction in payment.

Intelligent Claim Surveillance
Technology to Detect New and Emerging Fraud Schemes

TC³’s Intelligent Claim Surveillance employs dynamic profiling and predictive technologies using all available historical information to quickly identify complex fraud schemes, including sophisticated duplicate schemes, that previously could not be identified, and uncover new and emerging schemes – before claims are paid.

The software identifies patterns of unusual behavior and provides a risk score based on the claim's degree or probability of fraud. The scores allow TC³’s seasoned team of fraud investigators to determine which claims need to be taken out of the payment stream for further investigation, and allow the rest of the claims to be fast-tracked for payment.  

Case File Investigations
Prepayment Investigations Minimize Fraud Overpayments

TC³’s experienced investigative team uses the latest technology and a proven investigative process to maximize claims savings and minimize overpayments due to fraud and abuse.

TC³’s Investigative team members possess a good understanding of payer operations, and their investigative findings are reported in a manner that facilitates timely and effective use within our payer client’s organizations.

The investigative team conducts each investigation in an objective and professional manner, with unbiased presentation of the facts. TC³ investigators adhere to systematic, consistent methods to conduct investigations, yet recognize and handle the unique circumstances surrounding individual cases.  

Code Edit Compliance
Code Edit Compliance Utilizing Sourced and Documented Defense Rules

TC³’s code edit rules engine is the most comprehensive in the industry comprising millions of clinical edits. All rules and edits are based on national industry standards sourced, documented and defensible from CMS, CCI and AMA.

TC³’s code edit application is designed to minimize manual intervention as 100% of the edits are backed by nationally recognized coding guidelines and all rules include supporting documentation accessible through a web-based browser. The code edit rules egine can also provide additional PPO savings as billed charges are reduced when properly coded and the network discounts are calculated from a lower base.

OFACsecure^sm
Regulatory Compliance for the Patriot Act

TC³’s OFACsecure sm is an automated screening and compliance tool utilizing TC³’s advanced search and matching technology to correctly identify SDNs and to alert the compliance office of potential regulatory requirements. OFACsecure sm automates the search process, verifies identification against the SDN list and automatically flags questionable transactions.