We host tens of thousands of patients every year.
Fraud Prevention and Control
Fraud Prevention and Control
Fraud prevention and control is essential in international healthcare because billing standards, clinical coding practices, and market pricing vary widely. Without a structured fraud control layer, payers are exposed to inflated claims, unnecessary services, duplicated billing, and documentation gaps that are difficult to challenge after the fact.
We apply preventive controls and post-service reviews: invoice verification, clinical-document matching, anomaly detection (outliers in length of stay, consumables, pricing), and partner compliance checks. We also support dispute handling with evidence-based findings and recommendations for corrective actions and provider governance.
1) Establish control points during authorization and service delivery. 2) Validate billed services against clinical documentation and agreed terms. 3) Flag anomalies for deeper review and clarification with providers. 4) Provide a structured fraud/control report with rationale and outcomes. 5) Feed learnings into network governance to prevent repeat patterns.
We focus on practicality and defensibility: every challenge is documented with clear clinical and contractual references, enabling claims and audit teams to act confidently. This reduces leakage, improves provider discipline, and strengthens program integrity at scale.
Insurers and TPAs with cross-border exposure, corporates managing international health budgets, and public institutions requiring transparent, consistent control mechanisms and audit-ready reporting.
Scope of the Service
We apply preventive controls and post-service reviews: invoice verification, clinical-document matching, anomaly detection (outliers in length of stay, consumables, pricing), and partner compliance checks. We also support dispute handling with evidence-based findings and recommendations for corrective actions and provider governance.
How the Process Works
1) Establish control points during authorization and service delivery. 2) Validate billed services against clinical documentation and agreed terms. 3) Flag anomalies for deeper review and clarification with providers. 4) Provide a structured fraud/control report with rationale and outcomes. 5) Feed learnings into network governance to prevent repeat patterns.
Why Mest Assistance
We focus on practicality and defensibility: every challenge is documented with clear clinical and contractual references, enabling claims and audit teams to act confidently. This reduces leakage, improves provider discipline, and strengthens program integrity at scale.
Who This Service Is For
Insurers and TPAs with cross-border exposure, corporates managing international health budgets, and public institutions requiring transparent, consistent control mechanisms and audit-ready reporting.