Fraud Protection

With the high volume of claims MAA processes on a monthly basis, we understand the importance of sound operational procedures. MAA maintains automated and human processes established to monitor for fraudulent, excessive, or erroneous billing on a line by line basis.

Our programs include several automated safeguards and operational policies to prevent and protect fraudulent practices.

Claims System Editor

Our system causes any claim meeting specific detection criteria to be suspended and handled manually by a claims processor. The system has the capability to edit for many circumstances, including but not limited to:

  • Duplicate charges
  • Procedures performed on the wrong gender
  • Procedures performed on someone the wrong age
  • Billings over the usual and customary fees charged for that procedure in that geographic area
  • Unbundling of procedures. This is multiple procedures performed at the same site of the body. For example, if someone is having surgery on their lungs and liver at the same time, the doctor should not bill as if two surgeries were performed
  • Red flagged providers. Providers become red flagged when a claims processor or the system notes inappropriate or excessive billings from that provider
  • Billings from providers near the Mexico border. Historically, some "clinics" in Mexico used clinics in the United States for their billing.
  • Other insurance coverage for the patient whether it is a worker's comp/accident situation or the patient has other health insurance

Internal Controls

We have established several safeguards against internal fraud. These include such things as:

  • Background checks prior to hiring any employee including a check of a person's criminal record, financial record, and education and employment history
  • Eligibility and enrollment functions are also done separately from claims processing functions. Thus, an employee could not add participants and also process claims that would be payable to those participants. Provider maintenance is handled the same way for the same reasons.
  • Our claims system also provides security by feature and not just level of user. No employee is given access to a feature that is not required to perform his or her duties.

If Fraud is Suspected

If fraud is suspected, all documentation will be gathered and the client and plan participant is notified. Depending on the circumstances, the appropriate law enforcement agency and or licensing bureau will be notified. Fraud is an intentional act but sometimes mistakes are made. We are very careful to resolve these issues, thoroughly.