Q & A

About Our Services

Q - What services does Castlestone provide?

Castlestone uses existing payment networks to deliver real-time information to purchasers and overseers of healthcare. Our services prevent, detect and deter health insurance fraud. We also empower self-insured plans to create, manage and pay networks of their choosing.

Q - What are the advantages of using this service for healthcare fraud prevention?

Our technology is the only fraud prevention service in place to capture verified time, location and orders or codes in real time at the point of care.

Q - What is the estimated Return on Investment using Castlestone’s services?

The average cost of fraud or inappropriate claims for self-insured employees is between $1,085 and $1,860 per year, and our estimated monthly cost of service per employee is less than $3 per month. We piloted our services with the Medicare Durable Medical Equipment program, and the program estimated a 765% return on investment. The Government Accountability Office opined that we could address ¼ of health insurance fraud. We’d say affordable is an understatement.

Q - How quickly can automation be set up?

Implementation of Castlestone services takes from 30-45 days from contract signing to cards in employees’ hands.

Q - Who monitors the activity?

Castlestone clients have access to a portal to monitor and identify activity by member and by provider. The portal delivers reports about suspected frauds and anomalies. Clients may also opt for Castlestone’s team to monitor activity and highlight potentially fraudulent claims.

Q - How much time will it take to oversee the service?

Castlestone’s services require minimal oversight from those who pay the bills. The service will empower companies who pay the bills to determine which claims should be paid, and which are questionable. Checking the service only takes a few minutes per week. Castlestone monitors all outpatient activity and customers only need to address the exceptions.

Q - Are there any upfront costs?

There are implementation costs associated with portal customization as well as security, access, alerts, and reporting delivery setup.

Q - I use a TPA, is this an issue?

Great question! We are happy to work with TPAs. In our process, their main role is to send the (pending) claims file to a secure site so we can match it with the card network information we have received. Then, the customer can instruct the TPA which claims not to pay until resolved.

Q - When do clients see results?

Clients see results as soon as the service is implemented. We recommend using the service for at least a 2-year period to better measure effectiveness and provide sufficient data to calculate Return on Investment.

About Healthcare Fraud, Misuse, and Abuse

Q - Why doesn’t the insurance company monitor this for us?

Although insurance companies provide a great deal of services to employee-funded plans, there is no advantage for them to protect plans from fraud. Under ERISA, the plan sponsor is the beneficiary of fraud reduction or recovery, so carriers and administrators have minimal incentive to invest in reducing fraud. Therefore, employers carry the burden of protecting the plans, not the insurance company. Furthermore, insurance rates increase based on what was spent the previous year, so any fraud loss prevention reduces the cost of reinsurance the following year.

Q - Why is medical identity theft a growing problem?

Your health information is everywhere. It is on every system of every provider that an insured visits – doctors, physical therapists, laboratories, pharmacies, and more. This makes one’s identity vulnerable to hacking. Adding to this, the claims payment process cannot determine whether a claim comes from a legitimate office visit or a stolen identity. That is why stolen health insurance identities are worth between $250-$1,000 on the dark web. Employers and administrators have no tools to help monitor this process.