AUDITING – FRAUD, WASTE & ABUSE
Wise Medical Services employs an integrated medical auditing framework designed to safeguard financial resources and ensure full compliance with healthcare standards. Our auditing approach operates through two primary mechanisms: Offsite Audit and Onsite Audit, both conducted by a highly qualified team of medical auditors and certified coders.
2. Onsite Audit
Onsite audits are conducted through direct visits to healthcare providers based on:
• The most suspicious files identified by data analytics.
• Random or incidental visits when required.
• Provider feedback and operational logs.
Onsite audits aim to:
• Verify original medical records.
• Match billed services with services actually rendered.
• Ensure recovery of any overpaid amounts.
• Evaluate the quality and accuracy of medical documentation.
1. Offsite Audit
This process relies on a sophisticated digital system equipped with a built-in Rules Engine aligned with international auditing standards. The offsite audit includes:
• Detecting potential upcoding and inflated billing.
• Identifying duplicate or non-existent claims.
• Verifying prescriptions and the actual delivery of services.
• Assessing medical necessity for all procedures.
• Reviewing excessive or unjustified charges.
• Screening for indicators of fraud, waste, or abuse.
The system combines evidence-based healthcare management with provider utilization trend analysis to generate comprehensive, actionable insights.
he integrity of the entire health benefit system.
3. Fraud, Waste & Abuse (FWA) Controls
Wise’s coding and auditing team covers all aspects of FWA management, including:
• Detecting unnecessary or unjustified medical services.
• Identifying manipulation in coding or billing practices.
• Preventing waste through repeated or redundant procedures.
• Addressing intentional and unintentional misuse of benefits.
This comprehensive auditing structure ensures cost control, enhances transparency, and strengthens the integrity of the entire health benefit system.
