SOLUTIONS BRIEF

A NEW APPROACH TO COMBAT HEALTHCARE FRAUD

The pay-and-chase approach to fraud remediation cannot compete with the omnipresent danger of an increasingly sophisticated criminal element.
The cost of healthcare fraud poses a significant threat to private healthcare payers and undermines the integrity of public funded health programs such as Medicare and Medicaid. The National Health Care Anti-Fraud Association (NHCAA) estimates conservatively that 3% of all health care spending or $68 billion per yearis lost to health care fraud. For many years, healthcare payers have used a retrospective pay and chase methodology in their attempts to combat fraud and improper payments. However, healthcare fraud patterns are dynamic and quickly adapt to changes in post-payment recovery programs. The pay-and-chase approach to fraud remediation cannot compete with the omnipresent danger of an increasingly sophisticated criminal element. Forward thinking healthcare organizations have long sought systems and approaches that shift the payment integrity paradigm from a retrospective to a prospective state, helping prevent fraud prior to payment of improper claims. INTRODUCING A NEW APPROACH TO COMBAT HEALTHCARE FRAUD Verizons Fraud Management services bring an entirely new approach to healthcare fraud detection, employing integrated processes and a highly sophisticated data-reduction platform, capable of processing billions of transactions daily. The solution processes healthcare claims transaction data quickly and efficiently, applying domain-specific predictive models, artificial intelligence algorithms and risk scoring to identify and prioritize abnormal patterns indicative of healthcare fraud. Verizons Fraud Case Management module supports integrated case management from identification through investigation and enables appeals tracking and documentation of results. Verizon Fraud Management provides: High Volume Data Reduction Architecture. Reducing the initial input volume to a manageable and rich set of suspect cases for investigation by operations staff. Dynamically Configurable Predictive Modeling. Tools that support linear pattern recognition (heuristic, expert rules) and non-linear patterns (neural nets, clustering, artificial intelligence, etc.) Healthcare Fraud Models. Look for indicators such as high frequency utilization behaviors, geographic dispersion of participants (such as patient/provider) and identification of abnormal practice patterns. Case Prioritization. To focus resources on cases with the highest potential fraud impact. Flexible Data Integration Design. Providing non-disruptive integration with existing claims management data systems and business operations. FRAUD CASE MANAGEMENT Verizons Fraud Management services employ a holistic and procedure-driven architecture that enables identification of potentially fraudulent claims for more detailed review. Our integrated Case Management Workbench supports rapid response, first call resolution, and quality monitoring along with comprehensive workflow management tools and controls that help make staff members more efficient and productive. Key Performance Indicators (KPIs) measure critical performance metrics from the analyst level to the enterprise level.

VERIZONS FRAUD MANAGEMENT SOLUTION HELPS HEALTHCARE ORGANIZATIONS: Prevent losses before they occur due to fast, efficient pre-payment interventions Drive cost control over pay and chase approaches Monitor 100% of claims in near real time versus sampling methodologies Focus internal resources on investigation of suspect cases Improve workflows and increase productivity Respond quickly to a dynamically changing environment

Key Components: Fraud Case Management Workbench with easy to use web-based user interface and presentation layer to support healthcare fraud analysis Visual Graphic Analysis through link analysis and geo-mapping techniques which show the relationships between providers and beneficiaries Integrated and Configurable Workflow Tools to route fraud cases and alerts to appropriate staff, helping improve productivity and streamlining processes Case Activity Tracking, documentation, online notes, and incorporation of external documents with date and time stamps with complete audit trail DATA REDUCTION ARCHITECTURE In contrast to a large data repository that is queried/mined for analysis, Verizon Fraud Management is a streaming system for pattern recognition and anomaly detection. It finds the desired information by analyzing events and applying domain-specific, data reduction rules as illustrated below.
200,000,000 Data Reduction Point

Data Input

100,000,000 100,000 10,000 1,000

Normalization and Filtering Datafeed

Rules

Detection
Rules

Analysis
Rules

Prioritization
Rules

Presentation User

COMPREHENSIVE REPORTING TOOLS Verizon Fraud Management includes comprehensive reporting, data mining tools, and a large volume data warehouse for trending and analytics. Warehoused data will be available to investigators for trending, post data analysis and additional case development including preparation for submission to program integrity staff, audit organizations, law enforcement and other authorized entities. Examples of regular reports include: Financial Management, Trend Analytics, KPI/Performance Metrics, and Intervention Analysis Effectiveness. TEAM-UP WITH A LEADER IN INFORMATION SECURITY Verizon works with each individual customer to develop the rules and definitions to help identify potential fraudsters. We oversee the fraud management process and help adapt the model as fraud methods and trends change. Verizon Professional Services include program design and integration services. Our experts study your existing healthcare fraud operations, identify unique operational aspects of your organization and develop appropriate procedures. Well develop a transition program and train your staff in operating procedures. We also offer integration services to implement interfaces to your transaction processing systems. Verizon is a global leader in security solutions with an established professional services team and significant experience operating help desks and call centers around the globe. Our capabilities are consistently recognized by industry experts. For example, Gartner has placed Verizon Business in the leaders quadrant for North American managed security providers in 2010. The ever-changing healthcare landscape requires a dynamic fraud management strategy and the ability to execute that strategy. Verizon has the systems, processes, and people to help you reduce risk and contain costs related to healthcare fraud.
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