Financial losses due to healthcare fraud are estimated in the tens of billions of dollars each year. Mandated processing efficiencies, overlooked claims, overwhelmed or insufficient staff, disparate record systems, and incomplete reports and data sets can all create opportunities for fraud, waste, and abuse (FWA).
In addition, fraud activities are becoming more harmful to patients, due to medical identity theft, physical risk, and increasing coordination with organized criminal groups.
Designed with clinicians, claims and regulatory experts, administrators, and data analysts, Verscend’s FWA solutions adapt to emerging fraud schemes and compliance requirements. Part of the Payment Accuracy solution suite, our FWA solutions comprise a complete and integrated solution set for SIUs that use data analysis, decisions, and insights from one module to help modify rules and algorithms for other modules—creating an even stronger, anti-fraud solution.
- Reduce medical costs by recovering more dollars from FWA
- Prevent more FWA to avoid the costs of pay-and-chase
- Reduce false-positive leads and associated costs
- Increase SIU staff efficiency
- Achieve regulatory compliance
Our extensive clinical and investigative experience and industry-leading software delivers a complete end-to-end solution, including improved program compliance and documented return on investment typically ranging from 5:1 to 15:1. Our offerings are integrated but also flexible and modular:
- Sentinel—Support post-pay detection of suspicious activity with Sentinel, our automated, early-warning detection and overpayment protection system. It evaluates, compares, ranks, and scores providers and members for potential fraud, billing mistakes, or medical policy violations. Hundreds of patterns, rules, statistical calculations, utilization measures, financial profiles, and high-impact fraud schemes are used to identify an overall “Index of Suspicion.”
- Informant—Our advanced data analysis tool supports user-controlled exploration of healthcare data to discover irregularities and isolate questionable billing/payment patterns—great for when you may already suspect a provider, member or scheme. Informant can be used for self-driven data mining, or by our SIU Services team as part of your solution.
- Commander—This “command center” helps build, track, and learn from FWA caseloads. Commander uses calendars, notifications, and search to support proactive adoption and reinforcement of best practices in case prioritization, investigative work plans, inter-departmental collaboration, and industry-standard financial reporting. Quality review dashboards track goal progress, productivity levels, turnaround times, inventory levels, outcomes, and return on investment.
- Interceptor—Verscend’s pre-payment fraud detection tool uses a powerful analytics rules engine to identify and analyze inappropriate claims and claim patterns before they are paid. Interceptor identifies claims with aberrant patterns in utilization, coding mismatch, and billing-payment activities using a rules methodology. It also meets prompt-pay requirements, avoiding costly fines and penalties.
- SIU Services—Verscend provides a wide range of program integrity services, from augmenting in-house staff with investigative support, to providing a complete and comprehensive outsourced SIU. Types of services include:
- investigative support
Our expertise in Medicaid and Medicare supports a variety of claim investigations, including facility, professional, and pharmacy. Our investigative support services help organizations increase efficiency through a triage of hotline tips and external leads; assess the need for further investigation; conduct initial investigative analyses, including research and statistical sampling; review code; and create workflows to standardize and document processes.
- clinical review services
- Medical Review for Post-Payment and Pre-Payment Investigations: Verscend's skilled coders, nurses, and auditors help ensure coding practices remain appropriate and consistent with state and federal guidelines.
- Appeals Support: Our experts strengthen the appeals process through clinical perspectives and an in-depth understanding of FWA investigations.
- Pharmacy Lock-In Initiatives: Our clinicians provide detailed data analysis of member behavior (that may indicate abuse) and document recommendations to better deter fraud, waste, and abuse to protect beneficiary populations.
- claims verification services
Verscend's investigators and analysts compile verification results to support regulatory compliance and identify overlap and aberrant billing practices for states with Medicaid managed care organizations that require verification of services.
- consultative support
Our service offerings include compliance audit support, policies and procedures refinement, staff development planning, investigative skills training, and best practices consulting.
- Audit Preparation: Our experts’ preparedness and compliance support meet evolving and regular state and federal program audits.
- Policies and Procedures Documentation: Verscend helps organizations improve policies and documentation by reviewing procedures to maximize outcomes, institute safeguards, prevent process deficiencies, improve work plans, and meet evolving regulatory requirements. Our investigative and clinical staff conduct gap analyses of medical policies and payment guidelines to close the loop on wasteful providers, as well as identify state legislation that would impact a health plan’s use of statistical sampling and overpayment recovery periods.
- Reporting: Our industry experts assist health plans with generating complete and accurate reports to state and federal regulatory agencies.
Verscend is more than a technology vendor with a services support staff. We’re your expert, consultative partner in fighting FWA. We leverage more than 20 years of experience, and our widely-credentialed clinical and regulatory experts provide industry thought leadership, deliver training sessions, and advise payers on the latest schemes and anti-fraud approaches.
By using our highly efficient services team, one of the largest payers in the country pursued a $100M overpayment to a national DME firm which later settled for an undisclosed amount. Our team provided guidance to the payer, performed the statistical sampling, medical record review, extrapolation and expert testimony which the payer’s own staff could not perform.
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