Healthcare claims fraud
Pay for care. Not for phantom visits.
Fraudulent providers bill for visits that never happened, quote prior authorizations issued for other patients and bill the same service twice. Omnareth checks every claim against the member's coverage and history before it is paid, and recognizes the provider when it bills across many members.
| # | Event | Decision |
|---|---|---|
| 1 | Genuine MRI with its prior authorization | ALLOW |
| 2 | A clinic bills an office visit that never happened | DENY SERVICE_NOT_VERIFIED |
| 3 | The clinic bills an MRI on another member's prior authorization ▲ Repeat offender case; clinic watched |
DENY PRIOR_AUTH_INVALID · PRIOR_AUTH_REUSE |
| 4 | The clinic bills a therapy session already paid ▲ One provider across three members: case opened |
DENY DUPLICATE_BILLING · WATCHLIST_MATCH · REPEAT_OFFENDER · PROVIDER_HOPPING |
| 5 | A genuine visit billed above what the diagnosis supports | FLAG UPCODING_SUSPECTED |
| 6 | A procedure the plan does not cover | DENY SERVICE_NOT_COVERED |
| – | Analyst confirms the provider case ▲ Provider blocked everywhere |
analyst · state |
| 7 | A claims processor resubmits the clinic's claim, visit marked verified | DENY WATCHLIST_BLOCK · REPEAT_OFFENDER · PROVIDER_HOPPING |
| 8 | Genuine office visit | ALLOW |
How it fits
A check before money moves
Healthcare fraud hides in volume: each claim looks routine, and the pattern only appears across members. Your system sends each request to Omnareth and acts only on what it allows.
The member
Eligibility, the services the plan covers, the prior authorizations issued and the services already paid.
Provider claims
A claim must be for an eligible member, a covered service, a verified encounter and an authorization issued for this member, once.
One provider, many members
Omnareth holds the billing provider responsible, never the members billed for, and recognizes it across members.
Reference rules
12 rules, ready to adapt
Authorization checks fail closed, and every rule names who it holds responsible when it fires.
| Threat | What Omnareth checks | Rule code | Decision |
|---|---|---|---|
| Possible Upcoding | Flag claims whose diagnosis does not support the level of service billed. | UPCODING_SUSPECTED | FLAG |
| Duplicate Billing | A service by a provider on a date is paid once. | DUPLICATE_BILLING | DENY |
| Service Not Verified | A billed service must match a verified encounter (eligibility check, check-in or visit record). | SERVICE_NOT_VERIFIED | DENY |
| Member Not Eligible | Claims are paid only for members with active coverage. | MEMBER_NOT_ELIGIBLE | DENY |
| Prior Authorization Invalid | A prior authorization quoted on a claim must have been issued for this member. | PRIOR_AUTH_INVALID | DENY |
| Excluded Provider | Providers on a government exclusion list may not be paid. | PROVIDER_EXCLUDED | DENY |
| Service Not Covered | The procedure must be covered by the member's plan. | SERVICE_NOT_COVERED | DENY |
| Provider Across Members | Flag a provider or referrer implicated in denied claims for two or more other members in 24 hours. | PROVIDER_HOPPING | FLAG |
| Prior Authorization Reuse | A prior authorization belongs to one member; seen on another, it is likely copied. | PRIOR_AUTH_REUSE | FLAG |
| Repeat Offender | Flag events involving an identity implicated in two or more denied events in the last 30 days. | REPEAT_OFFENDER | FLAG |
| Blocked Identity | Identities blocked on the fraud watchlist may not take part in any member event. | WATCHLIST_BLOCK | DENY |
| Watched Identity | Identities under watch may proceed only with a flag for review. | WATCHLIST_MATCH | FLAG |
The insider case
Marked verified. Still not paid.
After the analyst confirms the case, a claims processor resubmits the clinic's claim with the visit marked verified. Every member check passes. Omnareth refuses it on the watchlist, and the audit record shows the block it acted on.
Victims are not suspects
Only the identities a rule implicates are held responsible. Genuine customers named in a fraud attempt are never counted against.
Policy as rules
Your checks run on every request, with the reason and a remediation step recorded.
For auditors and regulators
Every refused request is sealed with what was known at the time, and verifiable later.
Adapt the model
The Member model, its rules and its fraud identifiers are plain JSON you can change.
Pilot program
Put healthcare claims fraud prevention to work in 90 days
One lane, facility or process, in shadow mode, with results measured against criteria we agree with you. Qualified companies and organizations can apply.