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Baruch Antifraude & Segurança
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Healthcare and health plans

Fraud investigation for healthcare providers and health plans

Charges unsupported by care records, inconsistent reimbursement requests and undisclosed provider relationships require a joined-up review. Baruch investigates documents, approvals and payment flows, preserving evidence and distinguishing process failures from indicators of fraud to support decisions by operational teams and legal advisers.

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PRACTICAL APPLICATIONS

From the situation to investigation deliverables.

See which facts need clarification, the relevant services and the deliverable associated with each one.

SITUATION 01

Billing and reimbursements with conflicting records

Reimbursement requests contain similar receipts for different appointments, changed amounts or procedures absent from available records. The health plan needs to compare documents, authorisations and payments, examine the files’ origins and establish whether the issue involves duplication, error or suspected fraudulent billing.

Solutions that may help

Related deliverables

  • A timeline and reconciliation of the requests, care records, approvals and payments examined.

    Delivered throughFraud Investigations

  • An analysis of documents and digital records, including assessment of possible editing indicators, documented origin and preserved evidence.

    Delivered throughDigital Forensics and Analysis
Decision supported

Decide which requests need closer examination and which checking and approval controls need review.

SITUATION 02

Provider relationships needing clarification

A group of clinics generates similar requests and referrals to the same providers. Possible connections to intermediaries or approvers are not clearly disclosed in registration records. The organisation needs to verify these relationships and compare authorisations to investigate favouritism or coordinated conduct.

Solutions that may help

Related deliverables

Decision supported

Assess whether the relationship needs further checks, control changes or other measures.

Other signals worth investigating

  • Repeated charges for the same appointment or procedures unsupported by available records.
  • Changed reimbursement accounts and digital receipts showing signs of editing.

Illustrative situations, not client cases. Solutions and deliverables depend on the need, available information and agreed scope.

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REFERENCES

Sources to understand the risks.

Reference publications on the schemes and risks described in the examples.

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Baruch · Physical and cyber fraud

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