GOVERNANCE: Opportunities to Improve Controls over Medical Claim Payments

We found that the company appears to be identifying only a small portion of potentially fraudulent medical claims made by individual medical service providers. Our work indicated that 14 percent of claims submitted by physicians, nurses, physical therapists and other individual providers from 2013 to 2015 were potentially fraudulent, which is significantly higher than the 1 percent of claims identified by the company’s primary claim administrator.