g510 6087 combating hc provider fraud abuse

8/6/2019 g510 6087 Combating Hc Provider Fraud Abuse

http://slidepdf.com/reader/full/g510-6087-combating-hc-provider-fraud-abuse 1/4

Combating healthcareprovider raud and abuse

IBM Fraud and Abuse Management System

Center or Busin

Optimization

IBM Global Business Services



According to estimates from the federal government, and

from issues-based groups such as the National Health

Care Anti-Fraud Association (NHCAA), as much as 10 per-

cent of all healthcare expenditures in the United States

may be lost each year to fraud, abuse and waste.1 That’s

more than US$100 billion — coming largely from health-

care providers attempting to defraud the system. Methods

of cheating, such as billing for more expensive servicesthan those actually performed, or even conducting medi-

cally unnecessary procedures for the purpose of billing

insurance, have become more sophisticated and more

costly to payers. For example, the NHCAA reported that

one Texas chiropractor was caught submitting US$5.7 mil-

lion in fraudulent claims over a five-year period.2

Detecting fraudulent activity is not easy. Given the huge

volume of data involved, resource and process limitations

have forced many healthcare payers to rely on “pay-

and-chase” strategies, in which claims are paid and then

later — sometimes years later — investigated for fraud.

However, such after-the-fact collections are almost never

paid in full.

Recognizing the ultimate impact healthcare fraud and

abuse have on private health insurers, government-funded

health plans and consumers, IBM has worked closely

with healthcare investigators to develop the IBM Fraud

and Abuse Management System. A sophisticated, com-

prehensive solution with both proactive and retrospective

detection capabilities, the Fraud and Abuse Management

System helps healthcare payers identify and pursue fraudcases faster and more cost-effectively.

A full-spectrum solution

The Fraud and Abuse Management System supports

the various aspects of fraud investigation and manage-

ment, including prevention, investigation, detection and

settlement. Using a unique combination of data mining

capabilities and graphical reporting tools, the system can

identify potentially fraudulent and abusive behavior before

a claim is paid or retrospectively analyze providers’ past

behaviors to flag suspicious patterns. In either case, the

Fraud and Abuse Management System is designed to

operate more swiftly and effectively than traditional, manual

processes — sorting through tens of thousands of pro-

viders and tens of millions of claims in minutes, and then

ranking providers as to their degree of potentially abusive

behavior.

The easy-to-use reports and database wizard allows drill-down capability to profle, claims and other relational data.

Metropolitan Healthcare Plans

Provider Report Card

PE010 Ordered by Provider ID

Peer Group: CHIRLA ~ Los Angeles Area ChiropractorsValue Set: AB ~ LA Area Chiropractors - 2004 ~ 01/01/2004 - 12/31/2004Model: CHIRO2 ~ Chiropractic Model 2 ~ This model analyzes the practice, radiology, patient age as well as billing and volume ratiosProfle: 001 ~ LA Area Chiropractors - 2004

Groups: 7, Features: 44, Providers: 122, Owner: FAMSADMNProvider: 669317756 ~ J Peck

Element Description

Provider Composite Score

G1EXPOSURE Financial Exposure Group

EA0001 Overcharge Exposure Code

EB0001 Historical High Billing Score

FBG003 Total $ Charged

FBG007 Total # o Visits

FBG019 Total # o Patients

FBG020 Total # o Procedures

FBG160 Total $ Eligible

FBG333 Total # o Families

FBG334 Total # o Claims

G2RATIOS Practice Ratios Group

FBG006 Avg # o Pxs/Visit

FBG008 Avg # o Visits/Patient

FBG009 Avg # o Patients/Family

FBG014 Avg # o Diagnoses/Patient

FBG040 Avg # Procedures/Month/Patient

FBG061 Avg # Ofce Visit Svcs/Patient

1

5

1

16

79

113

27

119

113

80

2

8

4

24

12

1

9

827

392

H

1,000

211

59

6

168

14

5

28

822

863

992

219

695

1,000

893

39

869.99

55,769.00

172.00

11.00

735.00

9,055.00

8.00

87.00

4.27

15.64

1.38

2.82

19.86

3.64

24.36

23.13

0.00

20,032.00

32.00

7.00

200.00

5,717.00

4.00

6.00

0.00

1.21

2.29

1.00

1.44

1.93

0.00

210.99

131.87

75.00

31,709.50

209.50

32.50

473.50

18,286.00

27.00

120.00

146.76

2.25

5.94

1.23

2.20

4.43

0.64

827.36

660.03

869.00

177,505.00

1,124.00

233.00

2,725.00

120,512.00

181.00

818.00

846.26

10.66

20.86

2.25

4.00

19.86

15.55

0

0

5

5

5

5

5

5

5

5

5

5

5

5

5

5

5

Rank Score Value Minimum Median Maximum Weight



With the ability to drill down into detailed information on

each provider or claim, antifraud investigators and audi-

tors can zero in on questionable behavior, avoiding dead

ends and focusing on the most egregious offenders. What’s

more, IBM has built in a “point and click” graphical inter-

face, a reports and database wizard and extensive help

documentation that make the system relatively easy to

learn and simple to use.

A rapid return on investment

Not only can the Fraud and Abuse Management System

help speed and extend the ability to recover mistakenly

paid claims, but the system also promotes compliance

by providers and claimants, who quickly realize that frauddetection and enforcement have become more system-

atic and effective — an outcome known as the “sentinel

effect.” Additionally, by automating processes previously

conducted manually and by more accurately targeting

likely offenders, the system helps enable investigators and

auditors to become more productive, handling broader

caseloads and conducting a higher proportion of success-

“Through [the Fraud and Abuse Management System] Hospital Model, Aetna’s special

investigations unit (SIU) identifed more than 200 acilities with questionable outlier behav-

iors. To date, the SIU has pinpointed more than US$20 million in potential recoveries.”

— Benjamin S. Wright, business systems manager, Special Investigations Unit, Aetna

ful investigations. In fact, many healthcare payers realize

a significant return on investment within the first year of

implementation.

Turning analytics into action

The IBM Fraud and Abuse Management System is part of

the IBM Center for Business Optimization solutions port-

folio. The IBM Center for Business Optimization brings

together IBM’s industry and process expertise, hardware

and business performance software, and the company’s

deep computing and advanced analytics capabilities to

tackle our clients’ most difficult business challenges.

In addition to the area of risk management optimization,

the center offers solutions in the areas of marketinginvestment mix, dynamic pricing and complex supply

chain optimization.

The Fraud and Abuse Management System is driven by

the requirements of companies like yours — for example,

through collaborations with insurance organizations and

through our deep involvement with user groups — and is

constantly evolving as your business needs change.



© Copyright IBM Corporation 2005

IBM Global Business ServicesRoute 100Somers, NY 10589U.S.A.

Produced in the United States of America11-05All Rights Reserved

IBM and the IBM logo are trademarks or

registered trademarks of International Business

Machines Corporation in the United States, other

countries or both.

Other company, product and service names may

be trademarks or service marks of others.

References in this publication to IBM productsor services do not imply that IBM intends to

make them available in all countries in which

IBM operates.

G510-6087-02

For more information

To learn more about IBM Global

Business Services, contact your

IBM representative or visit:

ibm.com /bcs

To learn more about the IBM

Fraud and Abuse Management

System and the IBM Center for

Business Optimization visit:

ibm.com /services/cbo

References 1 National Health Care Anti-fraud

Association. “Health Care Fraud,A Serious and Costly Reality forAll Americans.” www.nhcaa.org. September 2002, p. 2.

2 National Health Care Anti-fraudAssociation. “Health Care Fraud,A Serious and Costly Reality forAll Americans.” www.nhcaa.org. September 2002, p. 4.

g510 6087 combating hc provider fraud abuse

Documents