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ClaimSentry is a suite of products from Reflective Medical that combines advanced technology and law enforcement experience to:

• Prevent suspicous claims from being paid (Prepayment Prevention Controls)
• Recover suspicous claims that have been paid (Postpayment Detective Controls)

 

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ClaimSentry Prevention delivers real-time preventive controls that stop fraudulent claims from being paid. It evaluates every claim prior to payment in, re-credentialing every provider and beneficiary. This software is configurable by each customer for their unique program requirements. It analyzes behavioral patterns, identifies anomalies and prevents claims payments from being made. ClaimSentry accuracy has been validated to 90% initially and gradually improves as program policies and regional characteristics are configured.

ClaimSentry is the final gatekeeper before a claim payment is made. Each claim is analyzed by ClaimSentry just before payment is made. If there are no issues, the claim is immediately paid. Claims that are identified as suspicious are delayed and reported to allow investigation.

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The identification of wrongdoers is based on the identification of risk factors including the following:

• Provider Behavior: ClaimSentry determines whether the provider's behavior mimic that of other providers who have been convicted of fraudulent behavior. The system also learns from past bad behavior and uses it to predict trends the future.


• ID Theft: ClaimSentry identifies potential ID theft of the beneficiary. ClaimSentry uses many advanced techniques to find suspected ID theft.


• Behavioral Anomalies: ClaimSentry utilizes artificial intelligence to identify claims that fall outside of normal profile/behavior of beneficiaries and/or providers. Beneficiaries who are not victims of ID theft and legitimate providers' behavior is generally consistent—if ID theft occurs the claim is aberrant to their normal behavior. This is much like credit card monitoring and ID theft.


• Use of External Data Sources: Criminal Medicaid providers and beneficiaries behave in predictable ways and artificial intelligence finds new trends in crime as they start. To completely analyze behavioral patterns and identify suspicious activities it is necessary to combine state claims
  information with other data sources. ClaimSentry matches beneficiaries and providers to external data sources to identify aberrant business practices.

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ClaimSentry Recovery evaluates paid claims to identify highly suspicious payments for potential recovery. ClaimSentry Recovery accuracy has been validated to 90% initially and gradually improves as program policies and regional characteristics are configured. Once required databases are received and imported into ClaimSentry Recovery, it only takes a few weeks before we can return initial results.

Based upon the initial results, we work with the health plan to recalibrate our filters ensure they reflect the characteristics of providers and beneficiaries and reflect the policies of the program. This process is repeated periodically resulting in improved accuracy and results.

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