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STAYING A STEP AHEAD OF BENEFITS FRAUD. THE POWER OF CLAIM WATCH.

With health benefits fraud reaching increasingly sophisticated levels, GSC's Claim Watch program kicks in to detect fraudulent activity and protect our plan sponsors' benefit spend.

THE CLAIM WATCH CONTINUUM

THE MULTI-LAYERED APPROACH THAT SETS US APART. WE COVER EVERY ANGLE.

The four segments noted in the inner ring above are the foundational elements of Claim Watch, positioning GSC to pinpoint collusion and shut down fraudulent providers.

Provider Registry

We are responsible for the administration and maintenance of the providerConnect™ National Provider Registry. This Registry records the name, credentials, and practicing locations of every provider named on every claim processed on our system. A provider has to submit an application for review and approval to be part of the Registry. Once a provider’s credentials have been verified, the provider is assigned a unique identification number. These numbers allow us to track and monitor provider claims activity from all locations they practice and against that of any other providers in the Registry.

We also operate providerConnect, a web portal that offers convenient online features for health service providers. It allows providers to:

  • Have payments deposited directly into their accounts
  • Submit an application for the registry
  • Submit PDT’s and check benefit eligibility online quickly and easily
  • View and print claims statements and history
  • Get access to forms
Advantage® System

We have a range of prevention strategies and policies available to help deter fraud and abuse, which are optional and can be included or excluded by plan sponsors. These include the following:

  • Automated rules built into our dynamic, rules-based claims adjudication system protect plan sponsors' benefit plans against fraudulent situations like dual benefit claiming or inappropriate billing
  • Price monitoring practices like our ‘usual and customary’ pricing guidelines are established for all eligible benefits and services to prevent over-billing by service providers and, in turn, overpayment by plan sponsors’ benefit plans
  • Built-in plan design controls encourage plan members to access appropriate and not excessive treatments
  • Superior data-mining tools make it possible for data from every claim entered into our system to be analyzed using our sophisticated reporting tools
Artificial Intelligence

In the past, preventing and detecting fraud involved manual processes, essentially the focus was on following a paper trail. Fast forward to today and AI technologies are able to not only find and compile masses of data like never before, but also to find patterns at both the individual and aggregate levels beyond human capabilities.

Basically, today’s range of data—that comes in a huge volume in all forms and from all directions—is impossible for people to compile, let alone make sense of it all. By contrast, our AI platform not only finds and compiles all kinds of data—at tremendous speeds—it also identifies patterns at a much more sophisticated level than we can.

Operations

Our Benefits Management and Investigation Services (BMIS) team is dedicated exclusively to claim investigation, audits, and fraud and abuse detection. The team consists of former law enforcement personnel, criminal intelligence officers, certified accountants and individuals with backgrounds in the financial and public sectors.

We also have a group of claims experts who know our business and systems better than anyone, and staff with extensive medical backgrounds, including pharmacy and dental.

Get more of the Claim Watch story. We love to share it.

The complexities of today’s fraud schemes call for the broadest possible lens when scrutinizing benefits activities - and that's Claim Watch. Our Account Executives are standing by to share more about how it works.