Fraud, waste & abuse

Qantev's advanced AI-driven FWA detection module detects complex over-billing and fraudulent patterns, at scale, and gives you actionable insights for investigation management.

72%

Anomaly detection hit rate.

35%

Increase in SIU team efficiency.

Features

Go beyond claims anomaly detection

75+ advanced machine learning algorithms to detect patterns of unnecessary, mislabeled and fraudulent services, giving actionable insights on potential savings and implicated providers.

Claim deduplication

Detects and flags unusually similar claims indicating potential fraudulent activity.

Pricing anomalies

Identifies discrepancies in billing rates compared to standard pricing for services.

Medical coding anomalies

Flags inconsistencies and errors in the medical coding of claims.

Hospitalization time anomalies

Highlights unusual lengths of hospital stays that deviate from norms.

Patient journey irregularities

Tracks and identifies deviations in a patient’s treatment journey.

Unnecessary treatments

Detects treatments and procedures that lack medical necessity or justification.

Document forgery detection

Identifies and flags potentially forged or tampered documents within claims.

Abnormal frequency of claims or condition

Detects unusually high claim frequencies or conditions suggesting fraudulent activity.

Abnormal readmission rate

Identifies abnormal rates of patient readmission indicating potential issues or fraud.

Undeclared pre-existing condition

Flags claims where pre-existing conditions were not disclosed during policy issuance.

Early policy cancellation

Monitors and reports on policies canceled suspiciously early after activation.audulent activity.

Upcoding & doctor shopping

Detects billing for higher-cost services and patients visiting multiple doctors for the same issue.

Abnormal medication prescription

Identifies suspicious patterns in prescription medications that deviate from norms.

Abusive referral

Tracks and flags unusual referral behaviors indicating potential kickbacks or overutilization.

Early fraud trend detection

Monitors and identifies emerging trends indicative of potential fraud at an early stage.

Case management

Real-time alert detection and automated scoring for prioritization, historical claims audit.
Case assignment and actionable checklist to guide SIU teams during investigation
Task and document management for efficient workflows.

Activity dashboards

Business KPI metrics: detection rate, hit rate, recovery rate.
Number of alerts and recoveries by alert types and by subjects.
Monthly evolution of processed alerts and recoveries.

Seamless integration pre and post payment

At prepayment via native integration with your claims management system that flags suspicious claims before reimbursement.
At prepayment via native integration with your claims management system that flags suspicious claims before reimbursement.

Analytics

SLA and fraud investigation monitoring based on real time KPIs for optimal performance.
Individual and team performance monitoring with customizable KPIs.

How it works