FraudLens

Automated pre-payment fraud/waste/abuse detection for healthcare payers


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FraudLens Fast Facts

Healthcare in the U.S. is a $3.8T industry with an estimated $760B in fraud, waste and abuse (FWA) annually… that is 12-14% of an insurance company’s total payout to providers impacting the cost of healthcare and harming both patients and taxpayers.

Fraudlens is a technology company that has developed a clinically intelligent platform designed for adaptability by our end user client for use with their claims payment processing solution resulting in excess of 3% FWA savings to an insurance company's bottom line. 

Key Highlights:

  • Company founded by Dr. Frank Din (dentist, informaticist and forensics expert), and Qasim Mueen (healthcare IT expert).
  • Raised $3.085M in seed funding, $5.5M convertible debt.
  • Developed dental solution targeting $12B in FWA and completed 8 proofs of concept.
  • Trademarked FraudLens, MedicaLens, and DentaLens.
  • At contract with large dental payer.  Licensing application worth $12.5M TCV.
  • Developing medical solution.
  • Completing patent application for clinically intelligent algorithm development.
  • Mentioned in the Gartner Healthcare Report: Hype Cycle for US Healthcare as one of the payment integrity solutions to watch for in the coming years.

The Problem

The $3.8T U.S. healthcare industry comprises as much as $760 B in fraud, waste and abuse (FWA) that isn’t being detected today. That is 12-14% of health insurance payers’ total annual paid to providers, physicians and facilities. The current solutions to detect FWA are not solving the problem.

Two problems continue to plague the integrity of the payment process;  manual reviews of approximately 10% of the largest claims, and payer’s move to an auto-adjudication process that pays claims fast without reviewing for FWA.    Both problems leave 90% of claims untouched or paid inappropriately. 

FraudLens is the only company focusing on the Right Payment Methodology  -   paying the right money to the right              provider on the right member for the right level of service.

Solution: The Right Payment Technology

Identify Confirm Prevent Eliminate

FraudLens designed, developed and deployed the right approach to solving this $760B problem. Our 3M+ configurable rules and several hundred specialty-specific clinically intelligent models & algorithms analyze all claims automatically.

FraudLens applies these rules and algo-rithms on all payer claims including low-dollar, high-volume and highly-repetitive claims resulting in recom-mendations of which claims to pay, which to reject and which to review. The files are returned the next day resulting in millions of dollars saved each year.   

By reducing inappropriate payer costs,
FraudLens saves 3-5% of the insurance payer’s total claim amount spent which goes directly to their bottom line!

This is The Right Technology!

How FraudLens Works

The insurance payer has an adjudication process that gets their claims paid fast.  We ask them to pause that process just before checks are cut to the providers.  They send us a file of claims data to be run through our clinically intelligent algorithms and business rules.  FraudLens sends a file back within  24 hours telling the payer which claims to release for payment and which         to hold . . . providing immediate ROI to the insurance payer.   

FWA Market

FraudLens recognizes that an estimated $500 - $760B in healthcare FWA is astronomically high and is revolutionizing the industry with clinically intelligent software to detect and prevent more than 3% FWA on insurance claims.

Business Model

Not all insurance payers have the same needs so we’ve made FraudLens flexible.   FraudLens has two business models; one is a percent of savings model and the other is a licensing model.  We share in our client’s savings or license the solution to them.  Either way, the savings goes right to their bottom line.

Shared savings: FraudLens receives 20% of the value of all claims that have not been paid by the payer as a result of our review for FWA and recommendation to them to forgo payment.  Fraudlens only gets paid when our technology performs.  There is no cost to the payer for use of our solution.

License fee:  The license fee is designed for larger health plans that want to install our solution along with their complimentary pre- and post-adjudication capabilities behind their firewall.  Because of our capabilities and intellectual property, we provide the solution to them for their exclusive use.   They feel so good about our technology they want to “own the code”.  FraudLens provides software updates and additional functionality as a part of the license fee.

Meet The Team

Qasim Mueen, Chief Executive Officer and Co-Founder
Founder of Zigron IT Services company focusing on IoT applications. Zigron Healthcare (acquired by Stella Tech. 2016), co-founder of TransparentHands.com

Kashif Mueen, Chief Technical Officer
Former CTO of Zigron Healthcare (exited 2016), CTO Wherever TV (IPO), 20+ years experience as an enterprise architect, product and platform de
velopment, R&D.
 

Michel Heitstuman, Chief Operating Officer
Entrepreneur with 20+ years experience in start-ups and multinationals; Dir. Business Dev. IBM, co-founder AOL Enterprise, CEO Brazil & VP Global Strategy Upaid Systems.

 

Robert Steele, Chief Sales and Marketing Officer
20+ years in the healthcare payment integrity business, understands the value of teamwork, building relationships and driving value both internally and with customers.  Closed over $750 million in Total Contract Value, called relentless by his colleagues. 

Yoemy Waller, Vice President of Integration
Long-term healthcare IT professional and data scientist with 20+ years experience in project management, big data, clinical and dental informatics, population health, and bioinformatics.

Javed Iqbal, Vice President of Technology
Working directly with the founders, Javed was the solution architect that led the team developing the intelligent analytic fraud solution for FraudLens.  12+ years guiding teams through all  phases of software development; system architecture & design, IT software.

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