Abstract: A method for controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, evaluating the information including at least one of determining indications of fraud, validating service coding and editing as indicated, identifying possible payment discounts, and developing analytics indicative of risk for future claims, and providing loss control recommendations based at least partially on the evaluation, prior to paying the claim. Also a loss control system for healthcare claims with a loss control engine and a database in communication with the loss control engine, wherein the loss control engine accesses information about healthcare claims from the database after the claims have been processed for payment and wherein the loss control engine further analyses the claims for potential cost savings and returns a loss control recommendation for each claim to the database before payment of the respective claim.

Abstract: A method of controlling healthcare claim payment losses including accessing claim information after a payer is prepared to pay the claim, but prior to payment, evaluating the information and developing a score indicative of loss control opportunities and if the score exceeds a threshold, flagging the claim to the payer for loss control opportunities else, recommending payment, wherein flagging of the claim or recommending payment of the claim occurs prior to payment. A healthcare claim loss control system including a database having data related to claims and a scoring engine in communication with the database wherein the scoring engine accesses data corresponding to a claim when the claim is ready for payment, but before payment occurs and wherein the scoring engine evaluates the claim for loss control opportunities and generates at least one score for the claim corresponding to the evaluated loss control opportunities before payment.

Abstract: A method of controlling healthcare claim payment losses including accessing information about a claim after a payer is prepared to pay, but prior to payment, applying at least one rule to the information, wherein the at least one rule is adapted to determine indications of fraud and if fraud is indicated, flagging the claim, else recommending payment, wherein flagging of the claim or recommending payment occurs prior to payment. Also, a healthcare claim loss control system including a database having data related to healthcare claims and a loss control engine in communication with the database wherein the loss control engine accesses data corresponding to a healthcare claim when the claim is ready for payment, but before payment of the claim occurs and wherein the claim scoring engine applies at least one rule adapted to identify fraud and flags the claim for any indicated fraud before payment of the claim.