HEALTHCARE

SmartBPM for Healthcare Fraud, Waste and Abuse Management

Key Challenges
The healthcare industry is challenged with fighting fraud and financial crime in an environment of ever-increasing fraud losses. Estimated at more than $226 billion by the FBI, the high cost of healthcare fraud, combined with the mounting need to reduce healthcare costs overall, has driven healthcare organizations to find better solutions to tighten internal controls, decrease manual management of fraud activities, and move fraud processing earlier in the claims payment cycle. This avoids costly post-payment recovery work while reducing fraud losses. Some of the key operational challenges today include:

Pegasystems industry-leading SmartBPM suite is used widely by healthcare organizations to drive improvements in productivity, control and automation throughout the healthcare enterprise. Used by five of the six largest healthcare payers and more than 55 percent of all Blues plans, Pegasystems SmartBPM technology provides foundational components for healthcare transaction automation in numerous areas including sales, enrollment, customer service, claims processing and care management, as well as fraud, waste and abuse activities. SmartBPM for Healthcare Fraud, Waste and Abuse Management provides core fraud and investigations management components for the healthcare industry. These components, including pre-defined work types and objects, foundational code and data sets, core work processes and decisioning, packaged user portals and UIs, follow industry best practices and standards. In targeting application of Pegasystems award-winning BPM technology to the high-yielding ROI area of fraud, waste and abuse management, healthcare organizations gain a powerful new tool for preventing fraud payments, increasing recoveries and improving overall operational efficiency.

f Managing the high volumes of claims and exceptions

generated by fraud detection systems and the monitoring of disparate suspicious activity before claims payment f The soaring cost and risk associated with manually processing high volumes of fraud alerts and claims f The cost associated with recovering fraudulent payments f Providing fully auditable processes while ensuring that timeliness, documentation and risks are managed f Lack of agility and timeliness in identifying and managing new fraud risks

The Solution

Pegasystems fraud, waste and abuse management technology combines deep healthcare expertise, financial crimes functionality and robust case management and control to drive heightened results for fraud containment to the healthcare industry. Pegasystems SmartBPM technology brings automation to the management of fraud alerts and investigations, thereby preventing losses before claims payment and radically reducing overall fraud, waste and abuse leakage. Fraud investigators are made more productive through Pegasystems solutions including realtime presentation of consolidated information, automated correspondence, next-step processing guidance, activity deadline monitoring, facile reporting and more. The system ensures rapid response to the latest fraud schemes by allowing authorized business owners to easily manage and change processes and automation criteria as new risks and fraud types are identified.

SmartBPM for Healthcare Fraud, Waste and Abuse Management

Key Features
Alert and Investigations Case Management
Administrators can include customized rules to manage each alert type and fraud type with real-time alert intake and resolution.

Common Healthcare Object and Data Model

authorizations, etc.)

f Packaged common objects (claims, providers, members, f Pre-built HIPAA and claims processing functionality f Out-of-the-box claims edits (pre- and post-adjudication)

Auto-Duplicate Search

and healthcare system interfaces (member/eligibility system, claims, provider, etc.) f Healthcare-specific code sets including ICD, DRG, CPT, etc.

f Identify any alerts that are duplicates, ensuring the

processing of one alert and the auto-resolving of what is deemed the duplicate, with a comprehensive audit trail

Case Templates

f Configurable investigative protocol and process flow f Configurable templates for complex investigations and f Comprehensive Case View f Single view of the alert and/or investigation including

templates based on fraud type top-level work types

Behavioral Resolution

f Auto-resolution of alerts that previously were deemed f Rules-based automation of stop-payment based on

false positives based on history and previous investigation previous known fraud investigation results, pre-payment vs. post-payment

f Preconfigured interface for alert and case enrichment f Link multiple alerts to investigations for clustered

360-degree view of case, member, provider and claim processing and analysis

Auto-Group

f Automated identification and grouping of related alerts

into single or multiple cases based on type of investigative case and case attributes, including related claims, alerts, and providers f Investigation of related alerts in one case to allow multiple alerts to be investigated and resolved by a single investigator

Visual Link Analysis Fuzzy Logic Search

f Visual link analysis of relationships f Use phonetic name search capabilities to identify potential

relationships during the investigative process

Auto-Risk Rate

Rules-Based Fraud Process Management

f Rules to manage internal control gaps, ensuring

f Each alert and case is automatically risk rated, allowing

prioritization of alerts and cases f Alert ratings received from disparate monitoring systems and manual sources are normalized to ensure consistent rating and prioritization of alerts and cases f Dynamic change in risk rating as attributes change, including but not limited to previous fraud history, type of suspicious activity and number of alerts f Auto-routing alerts and cases based on risk rating

timeliness and compliance with regulatory requirements and risk-based fraud management

SLAs

f Configurable service levels for alerts and investigations to

ensure regulatory and internal control management

Real-Time Reporting

Investigation Case Management

referrals (e.g., law enforcement)

f Automated case creation from detection systems f Manually generated cases for non-detection system f Dynamically presents the correct investigative processing

Customized reporting wizard, including: f Trending on types of suspicious activity f Fraud losses and recoveries f Resolution time f nvestigator productivity

Built-in Auditing Agility

options for investigators based on type of investigation f Automated case enrichment with customer data, related alerts and claims history f Intelligent documentation management f Automated correspondence

f Real-time, inalterable audit trail f Use of familiar business tools by authorized business

users to manage and change processes as new risks and fraud types are identified f Easily change escalation activities, processing deadlines, divert specific claims, and so on

For more information, please contact your Pegasystems representative, visit us on the Web at www.pega.com, or email us at info@pega.com. Copyright 2010 Pegasystems. All rights reserved.

2010-11