Those who seek to commit healthcare fraud and abuse are continually adapting. Often, they fly just under the radar, with billing behavior that's not quite bad enough to be identified by claim systems looking at just a single provider or within just one payer’s claim patterns. Verscend Technologies’ Fraud Detection solution combines advanced analytics and clinical investigative review to deliver actionable case referrals to cost containment staff and special investigations units (SIU). The result is pre- and post-pay protection from aberrant billing and known and healthcare fraud and abuse emerging fraud schemes.
Clients report savings to us of between $0.40 and $1.70 per member per month.*
Verscend’s collaborative team of data scientists, clinicians, and investigators develops and maintains multiple levels of analytics to detect outlier billing behavior. Our analytics evolve along with creative fraudsters and the changing healthcare landscape. Approaches include:
An analytics data dump can cause investigators to spend an average of 65 percent of their time reviewing false-positive results. Verscend employs a dedicated team of clinical analysts and fraud experts within our own clinical investigations unit (CIU) to review and validate our system results prior to sending them to the client’s SIU. Clients can then focus on only the providers and claims identified as suspect, reducing wasted time on false positives and increasing case open rates.
Verscend delivers our analytic-driven allegation referrals via a true production application, which our own CIU and the plan’s SIU use together to drill down into the data for greater detail. Allegation summaries provide a clear presentation of all facts, including the suspect provider(s) and their behavior, visualization to help conceptualize the findings, a list of patients associated with the allegation, and recommendations for further action. This tool helps plans meet timely reporting mandates and the burden of proof required by state law enforcement.
Our optional case tracking tool is a comprehensive and highly customizable workflow management tool and information repository. Offered as an ASP solution, the tool minimizes the administrative time and resources needed for complex investigative case tracking and reporting to law enforcement through features such as activity tracking, financial tracking, and more.
Verscend’s nurse analysts and certified professional coders review medical records for payment accuracy comparison to the claims submitted by a provider. After analyzing chart notes, dates of service, treatments, diagnoses, and prescriptions, they securely deliver a report to the client.
Fraud Detection is part of Verscend’s suite of end-to-end Payment Accuracy solutions. Because the solutions all share one data feed across integrated platforms, clients can take a prioritized, incremental approach to rolling out our full suite of offerings, yet must only undergo one implementation process. In other words, once you have one component up and running, the others can be added by essentially just turning them on. This approach allows you to launch new capabilities faster while saving you money.
* Individual results will vary by client.
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