Fraud Detection

reduce the costs of fraud, waste, and abuse

the facts

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.*

benefits

  • Improve prevention and recoveries
  • Reduce the time and effort needed to validate fraud allegations
  • Reduce false-positive allegations and open more cases
  • Comply with state Medicaid program integrity requirements
  • Simplify complex case tracking

multi-layered detection analytics that inform and evolve

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:

  • Suspect behavior algorithms. We offer more than 130 algorithms either pre- or post-pay with nearly infinite permutations. These algorithms detect suspicious or extreme outlier behavior related to peer group norms for specific combinations of procedures, diagnoses, and/or modifiers learned through our interactions with clients and industry experts.
  • Time series models. Time series models seek to detect changes in billing behavior relative to a provider’s historical billing as well as their peer group.
  • Spatial models. Geographical attributes of members and providers help determine abnormal behaviors in distance traveled, outliers compared to regional norm, and other geographical risks.
  • Network analytics. This approach identifies suspect relationships among networks of providers and members that could indicate potential collusion (also known as “steering”) or kickbacks among providers.
  • Supervised and unsupervised learning. Our semi-supervised learning approach builds on an existing list of known “aberrant providers” and identifies new providers who share similar characteristics with the fraud cases.

clinical investigative review for actionable referrals

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.

a production application that increases efficiency

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.

case tracking for reduced complexity

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.

cost-saving implementation and pricing

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.

a single integrated implementation for flexibility and future savings

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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fraud detection flowchart

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